Custom Fee Schedules¶

The Custom Fee Schedules feature allows organizations to define and manage their own fee schedules, which can override or supplement standard CMS fee data.

Overview¶

Custom Fee Schedules provide a flexible way to manage pricing for specific HCPCS/CPT codes. You can create multiple fee schedules, each with its own set of items (code, modifiers, pricing).

How Pricing is Applied¶

When a claim is processed, the system looks for matching fee schedule items based on: 1. The billing code (HCPCS/CPT) 2. Any modifiers on the line 3. The service date (must fall within effective/termination dates) 4. The contract ID (if specified)

Pricing Types¶

Custom fee schedules support three pricing types:

Flat Rate¶

The simplest pricing method. Enter a fixed dollar amount, and the system multiplies it by the number of units.

Formula: Payment = Pricing Amount × Units

Example: Code 99213 with Flat Rate $125.00 and 2 units → $125 × 2 = $250

Percentage of Charges¶

Prices the line as a percentage of the billed charges. Enter the percentage as a decimal value.

Formula: Payment = Billed Charges × Pricing Amount

Example: Code 99213 with Percentage 0.75 and $200 charges → $200 × 0.75 = $150

[!TIP] For 80% of charges, enter 0.80. For 110%, enter 1.10.

Multiplier (CMS-Based)¶

Multiplies the CMS fee schedule rate by a factor. The system first calculates what CMS would pay, then applies your multiplier.

Formula: Payment = CMS Rate × Pricing Amount × Units

Example: Code 99213 with Multiplier 1.20 and CMS rate $95 → $95 × 1.20 × 1 = $114

[!IMPORTANT] Multiplier pricing requires the code to exist in a CMS fee schedule (Physician, Lab, DME, or Ambulance). If no CMS rate is found, the line will not be priced.

Fallback to CMS¶

When "Fallback to CMS" is enabled on a fee schedule configuration:

• If a code is not found in your custom fee schedule, the system will automatically look up and apply the standard CMS rate
• If a code is found in your custom fee schedule, it uses your custom pricing exclusively

When disabled: - Codes not in your custom fee schedule will not receive automatic pricing - Only codes explicitly defined in your schedule will be priced

[!NOTE] Fallback to CMS is useful when you only need to override pricing for specific codes while using standard Medicare rates for everything else.

Global Multiplier¶

The Global Multiplier applies a percentage adjustment to all CMS-based pricing when no line-specific custom pricing is defined.

How it works: - When a code falls back to CMS pricing (no custom item match), the calculated CMS rate is multiplied by this factor - If user-defined custom items (Flat Rate, Percentage, or Multiplier) apply to a line, the global multiplier is not applied - Default value is 1.0 (no adjustment)

Formula: Payment = CMS Rate × Global Multiplier × Units

Example Use Cases: | Scenario | Multiplier | Effect | |----------|------------|--------| | Pay Medicare rates | 1.0 | No change | | Pay 120% of Medicare | 1.20 | 20% increase on all CMS rates | | Pay 90% of Medicare | 0.90 | 10% discount on all CMS rates |

[!TIP] Use Global Multiplier to inflate or deflate Medicare rates across the board, while still allowing specific codes to use custom line-level pricing when needed.

Managing Fee Schedules¶

Creating a New Schedule¶

1. Navigate to Customizations → Custom Fee Schedules in the dashboard sidebar.
2. Click the Create Schedule button.
3. Enter a Name (e.g., "2025 Commercial Rates") and optional Description.
4. Set the Effective Date and optional Termination Date.
5. Choose whether to Fallback to CMS rates for unmatched codes.
6. Set a Global Multiplier to adjust all fallback CMS rates (default is 1.0).
7. Click Create to save.

Managing Schedule Items¶

Click the "View" button on any fee schedule to manage its items.

Adding Items¶

1. From the schedule detail page, click New Item.
2. Fill in the item details:
3. Code Type: Select HCPCS.
4. Code: The specific billing code (e.g., 99213).
5. Modifiers: Optional modifiers (comma-separated).
6. Pricing Type: Select Flat Rate, Percentage, or Multiplier.
7. Amount: The pricing value (see examples above).
8. Effective Date: When this price becomes active.
9. Click Save.

Bulk Import¶

(Coming Soon) Functionality to upload CSV files for bulk pricing updates.

Audit Log¶

Every change to a fee schedule or its items is tracked in the Audit Log.

Viewing History¶

1. Open a Fee Schedule's detail page.
2. Click the Audit Log tab.
3. You will see a chronological list of actions (Create, Update, Delete).
4. Click the View (eye icon) button on any row to see full details, including:
5. Who made the change (User ID).
6. Exact time of change.
7. Before and After values (for updates).

Fee Schedule ID¶

Each Custom Fee Schedule has a unique ID (UUID) displayed in the detail view header. You can copy this ID to reference the schedule in other parts of the system or API calls.