Encoder-Plus For XP/Win7™ is a stand-alone application for Windows that provides complete DRG and APC calculation functionality along with optional ASC reimbursement calculation. Specifically, our Encoder-Plus For XP/Win7 product includes 2 fiscal years of DRG calculation, optional inpatient DRG reimbursement capability, the complete set of Outpatient Code Edits (OCE), the Correct Coding Initiative edits (CCI), and APC Assignment and APC reimbursement that is 100% compliant with CMS OPPS specifications. We include a national provider file so you can compute reimbursement for any Medicare hospital in the U.S. In addition Encoder-Plus includes the CMS Clinical Lab fee schedule to price lab items that are billed on APC cases, and also includes the complete ICD9 diagnosis and procedure and CPT/HCPCS Level II coding information. This functionality makes Encoder-Plus For XP/Win7 a very powerful tool for:

• Claims processing applications
• Data warehousing and data analysis
• Claim review
• Compliance auditing
• Re-pricing applications and more.

Developed in conjunction with the insurance processing industry and medical records professionals, Encoder-Plus For XP/Win7 has the features you need to complete the job quickly and accurately.

Request a Free 30-day Trial Version of Encoder-PlusFor XP/Win7.

PRICERActive™ Medicare Reimbursement Components have been integrated with Encoder-Plus For XP/Win7 to implement the full Medicare Inpatient PPS DRG Reimbursement capability. Calculate the acute-care Medicare reimbursement, including cost outliers where applicable, for any Medicare hospital in the U.S.! Request a Free 30-day Trial Version of Encoder-Plus with PRICERActive to download.

The standard version of Encoder-Plus For XP/Win7 includes 2 fiscal years of CMS inpatient DRG calculation and 7 years of APC calculation functionality. Also Available: Encoder-Plus For XP/Win7 - Enhanced Version with 5 fiscal years of CMS DRG calculation and complete APC calculation functionality

Features of Encoder-Plus For XP/Win7:

DRG Calculation
APC Assignment and Reimbursement Calculation
ASC Payment Calculation
DRG Reimbursement Calculation System
Batch Processing/Data Interface Capabilities
Output Options
Case History Log
ICD9 Diagnosis and Procedure Encoder System
CPT/HCPCS Level II Encoder System
Data Entry/Encoder Access
Length of Stay Computation
Data Validation
Error Processing Subsystem
Data Entry Modes
Case Processing Modes
DRG Weight/Reimbursement Analysis
Multiple Updateable DRG Weight Tables
Encoder-Plus Reports
DRG/MDC Reference
Help
System Requirements

Encoder-Plus For XP/Win7 is simply the most versatile DRG/APC/ASC Calculation and Encoding software available today!

DRG Calculation

The Diagnosis Related Group (DRG) is the primary component of health care claims reimbursement determination for Medicare. DRG specifications are produced and maintained by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Dept of Health and Human Services. Patient information including age, sex, and discharge status along with detail diagnosis and procedure code data from the patient record are processed through a complex algorithm to calculate the DRG. Associated with each DRG are weighting factors and statistical averages for the length of stay in an inpatient hospital. These data, when combined with hospital-specific cost factors are used to compute Medicare reimbursement for a hospital stay. For FY08 and after beginning with discharge dates of 10/1/07, Encoder-Plus now incorporates the new Medicare Severity DRG (MS-DRG) as mandated by CMS.

Encoder-Plus For XP/Win7 is a complete system for the calculation and analysis of the Diagnosis Related Group (DRG) and includes 2 fiscal years (optionally five fiscal years) of DRG specifications. Analysis features like DRG Weight Optimization show the coding and pricing options present with a case. Medical records personnel or claim reviewers can use Encoder-Plus to assure that claims will have the appropriate reimbursement from Medicare, an HMO/PPO or other payer. The built in reimbursement calculation system will compute an estimated reimbursement for each case. The PRICERActive DRG Reimbursement option is available for computing detail Medicare reimbursement for any of the Medicare hospitals in the U.S.

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APC Assignment and Reimbursement Calculation

The APC functionality for Encoder-Plus For XP/Win7™ was developed in response to the implementation of the Medicare Outpatient Prospective Payment System (OPPS). The Omnibus Budget Reconciliation Act (OBRA) of 1986 called for the development of a prospective payment system for outpatient care. The OPPS developed by CMS is the outpatient equivalent of the inpatient DRG-based PPS. The basic unit of payment in the inpatient PPS is a hospital admission while the basic unit of payment in the OPPS is an outpatient visit.

Encoder-Plus For XP/Win7 includes a complete system for editing and reimbursement of hospital outpatient procedures based on the CMS Outpatient Prospective Payment System (OPPS). An APC (Ambulatory Patient Classification) is calculated for each applicable line item on the claim.

Encoder-Plus For XP/Win7™ performs the following functions when processing a claim:

• Handles up tp 100 line items per claim
• Edits a claim for accuracy using full Outpatient Code Editor (OCE) specifications and CMS Correct Coding Initiative (CCI) edits
• Assigns APCs
• Assigns CMS-designated status indicators
• Assigns payment indicators
• Computes discounts, if applicable
• Determines the disposition of a claim based on generated edits
• Determines if packaging is applicable
• Determines payment adjustment, if applicable

Encoder-Plus For XP/Win7™ computes the APC reimbursement, coinsurance amounts, and applicable outlier amounts for each line item using the same pricing factors and formulas used by Medicare. Encoder-Plus includes a national provider and will calculate a geographically adjusted APC reimbursement for any Medicare hospital in the U.S. Encoder-Plus includes the CMS Clinical Lab fee schedule to price lab items that are billed on APC cases.

Note: Encoder-Plus For XP/Win7™ is not a full Medicare outpatient claims system. Reimbursement for other non-OPPS services subject to other Medicare reimbursement methodologies or fee schedules is not calculated by Encoder-Plus.

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ASC Payment Calculation

Encoder-Plus For XP/Win7 includes an optional capability for calculating the Medicare reimbursement for Ambulatory Surgical Centers (ASC) according to the revised ASC specifications effective 1/1/08. The ASC reimbursement is calculated for each applicable line item on the claim according to the CMS reimbursement specifications. Encoder-Plus For XP/Win7 can calculate CMS compliant ASC reimbursement for any Medicare facility in the U.S.

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DRG Reimbursement Calculation System

Encoder-Plus For XP/Win7 calculates an estimated reimbursement for each case processed. Reimbursement is calculated using the DRG Weight and the facility Blended Rate. Per Diem amounts are calculated for cases with an 02 discharge status. Encoder-Plus maintains multiple rate iterations, each with an effective date, for accurate pricing. Total charges are entered for each case and Encoder-Plus will calculate the variance between reimbursement and charges.

Optional PRICERActive™ plug-in component that is available for Encoder-Plus For XP/Win7 duplicates the reimbursement calculations used by Medicare for inpatient hospital claim payment. PRICERActive™ uses the same formulas and Medicare hospital-specific data that the Medicare intermediaries use to calculate claim payments and calculates all components of a Medicare PPS payment including:

• Federal Specific Portion
• Hospital Specific Portion (where applicable)
• Capital-related Portion
• Cost Outlier Portion
• Indirect Medical Education Adjustment
• Disproportionate Share Adjustment
• New Technology Add-On

With the PRICERActive™ option Encoder-Plus For XP/Win7 can calculate detail DRG payments for any Medicare hospital in the U.S. The PRICERActive™ option can also be set to compute Medicare reimbursements according to the rules for a Medicare HMO.

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Batch processing/Data Interface Capabilities

Encoder-Plus For XP/Win7 includes powerful features for importing and exporting data from other applications and performing batch processing. These features provide flexibility and adaptability to virtually any environment. Encoder-Plus For XP/Win7 can accept data directly from a number of database and spreadsheet programs including Microsoft Access, Microsoft Excel, Lotus 1-2-3, and dBase. In addition, Encoder-Plus For XP/Win7 accepts comma-delimited files that can be created from many other types of software including Microsoft SQL Server or Oracle databases.

One of the chief data interface mechanisms in Encoder-Plus For XP/Win7 is our Input/Output (I/O) Format Builder. This powerful feature allows Encoder-Plus For XP/Win7 to be easily customized to accept data in the format you already have instead of having to develop a specialized interface. Output data formats can be customized to the data file format of another application making it easy to pass DRG results data on to other systems or data repositories. Data files can be exported to database or spreadsheet programs for further analysis or reporting. These powerful but easy-to-implement features make Encoder-Plus For XP/Win7 a very powerful tool.

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Output Options

Encoder-Plus For XP/Win7 offers multiple Output Options for maximum flexibility. Processing results can be directed back to the screen, printed, or formatted into a data file that can be passed to other systems and applications, data repositories, etc.

The Data File Output option allows the user to export data in a formatted file. This data can be passed to other applications. The output filename extension determines how the file will be processed. The following associations are made between filenames and file types:

• .MDB: Microsoft Access Database
• .ACCDB: Microsoft Access Database
• .CSV: comma-delimited file format
• .XLS: Microsoft Excel spreadsheet
• .XLSX Microsoft Excel spreadsheet
• .DBF: dBase Database
• .WKS, .WK1: Lotus 1-2-3 spreadsheet
• as well as anative ASCII file format for the claim
type

Interactive Mode Screen Displays list all codes, descriptions, DRG/APC/ASC detail results, and reimbursement amounts for the case being processed. Also edit error messages, if any, will be displayed on screen.

Printed Reports are available for DRG/APC/ASC cases from all entry and processing modes.

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Case History Log

Encoder-Plus For XP/Win7 includes an optional Case History Log that maintains detail of all cases processed. Numerous options are available for selecting and displaying data by patient or date criteria. Complete detail for an individual case is available by double clicking the desired record. Data in history can be selected and exported to other applications, printed reports can be generated, and cases can be re-processed.

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ICD9 Diagnosis and Procedure Encoder System

Encoder-Plus For XP/Win7 includes a complete ICD9 Diagnosis and Procedure Encoder system for the selection of codes to prepare a claim for submission. Full information is available about the codes, including code usage notes, coding inclusions and exclusions, and fifth-digit category definitions. In every sense, Encoder-Plus is an electronic ICD9 coding manual. It is NOT an artificial intelligence type system that selects the appropriate code for you. It IS a tool that provides all coding information necessary for you to make the correct coding decisions, while saving valuable time through easily accessible features.

The Diagnosis and Procedure Encoders are intended to be accessed from the data entry screen to combine coding and DRG calculation activities. The code selected from the Encoder will be returned directly to the data entry field. The Encoder can also be accessed from the main menu for reference purposes. The Encoders utilizes light-bar type menus. The user only needs to position the light bar and press enter or click the mouse to make desired selections. Detail code information is accessed through pop-up windows from the Encoder screens.

The Diagnosis and Procedure Encoders contain an Index Search feature. This function allows the user to access the ICD9 Vol. 2/Vol. 3 Index by the major keywords. Find and Repeat Find functions allow the user to search for terms and subterms to select the appropriate code. The Vol. 1 ICD9 Tabular List information is accessible by a single keystroke.

Direct access to 3-digit code categories is also available from the Encoder Main Menu. This feature is particularly useful for experienced ICD9 coders. This function takes you to the desired category and displays all the 4 and 5 digit codes for that category.

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CPT/HCPCS Level II Encoder System

Encoder-Plus For XP/Win7 includes a complete CPT/HCPCS Level II Encoder system. Full information is available about each CPT and HCPCS code, including code usage notes and all detail information. In every sense, Encoder-Plus is an electronic CPT coding manual. Like the ICD9 Encoders, It is NOT an artificial intelligence type system that selects the appropriate code for you. It IS a tool that provides all coding information necessary for you to make the correct coding decisions, while saving valuable time through easily accessible features.

The CPT Encoder is intended to be accessed from the data entry screen to combine coding and case processing activities. The code selected from the Encoder will be returned directly to the data entry field. The Encoder can also be accessed from the main menu for reference purposes. The CPT Encoder contains a Keyword Index as the primary interface for the encoder. Select the desired topic and detail CPT codes are displayed. Please note that the alphabetic index is not a substitute for the main text of CPT. Please refer to the main text to ensure that the code selection is accurate.

The CPT Encoder also has a CPT 'Book' interface and utilizes light-bar type menus. The user only needs to double click the desired item or position the light bar and press enter to make selections. Detail code information is accessed through pop-up windows from the Encoder screens. The Direct Code Access feature allows the user to go directly to a particular CPT code. From there, detail analysis and selection can be made. This is useful for experienced users of CPT coding or if you just want quick access to the detail code information.

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Data Entry/Encoder Access

The Encoder-Plus For XP/Win7 data entry screen is formatted for logical entry of all discharge information. All required fields are clearly marked. Detail information about each field is available by positioning the cursor on the field in question and pressing F1. A window containing usage information about the field, editing performed, and reporting is displayed. After all data has been entered, all elements are edited for validity. If any errors or missing data elements are noted, error messages will be displayed in the right-hand portion of the entry screen. The user must then correct the errors before proceeding.

Encoder-Plus is designed to combine both the encoding and DRG calculation functions in one step. Both the Diagnosis and Procedure Encoders are accessible from the DRG data entry screens. By placing the cursor on the diagnosis or procedure code field and pressing F1, access to the Encoder is invoked. The code selection made within the Encoder is returned directly to the data entry field.

The CPT Encoder, as well as the ICD9 Diagnosis & Procedure Encoders are accessible from the APC/ASC case data entry screens. By placing the cursor on the HCPCS code field and pressing F1, access to the Encoder is invoked. The code selection made within the Encoder is returned directly to the data entry field. The data entry screen also has an encoder for CPT Modifiers that is available when the cursor is positioned on the modifier field. The HCPCS code must first be entered before the modifier list can be accessed.

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Length of Stay Computation

Encoder-Plus For XP/Win7 will compute the Length of Stay (LOS) for each DRG discharge case. After the admission and discharge dates are entered on the data entry screen, the LOS is computed. The LOS is displayed on all Encoder-Plus output screens, reports, and is carried through to the output file generated from the File Output Option. Encoder-Plus computes the LOS just as Medicare will, the number of days between admission and discharge, not counting the day of discharge.

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Data Validation

Encoder-Plus For XP/Win7 incorporates complete validation of all data elements. Patient age, sex, discharge information, and a principal diagnosis are required for each case. All diagnosis and procedure codes are edited to be valid ICD9 codes. Additional Medicare Code Edits are performed to validate diagnosis and procedures codes against patient age and sex. Diagnosis and procedure codes are edited for being applicable only to male or female patients. Diagnosis codes that fall into categories of newborn, pediatric, maternity, and adult diagnoses are validated against the patient age. A series of edits are also performed to exclude manifestation codes, non specific codes, and E-codes as principal diagnosis. All the above edits are performed to Medicare specifications.

Encoder-Plus For XP/Win7 includes the complete set of Outpatient Code Edits (OCE) as part of the processing of APC cases. All data editing is performed to CMS OPPS specifications.

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Error Processing Subsystem

Encoder-Plus For XP/Win7 includes an Error Processing Subsystem that provides a way for the user to temporarily store a case with errors without losing the data that has already been entered. If an error occurs that cannot be immediately resolved, it can be written to an internal error file for later resolution. Cases are written to the error file during the entry and edit functions of either single case, multi-case, or file-entry input modes by clicking the 'Save Data to Error File' button. Encoder-Plus defaults to writing batch processing cases that have edit errors to the Error File. Cases can be re-processed from the error file after further research or verification is performed. Reports can be printed and unwanted cases can be deleted from the error file.

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Data Entry Modes

Encoder-Plus For XP/Win7 incorporates multiple data entry to provide flexibility and adaptability to many environments. These data entry modes are summarized below:

Single Case Entry Mode

Single Case Entry Mode allows the user to enter and process a single DRG/APC/ASC case. Data is entered via the screen and is edited for validity. Help information, including data edit specifications, is available for each field on the data entry screen . The Diagnosis, Procedure, and CPT Encoders, as applicable, are accessed by double clicking the diagnosis, procedure, or HCPCS code field. The code selected is returned to the entry screen. After data has been entered and validated, processing is performed in Interactive Mode. Once processing is complete, the user can edit and re-process the case or proceed to the next. The encoders can be accessed during re-edit. From Single Case Entry Mode the user can print a Detail Report for the completed case.

Multi-Case Entry Mode

Multi-Case Entry Mode allows the user to enter and process multiple cases. Data is entered via the screen and is edited for validity. Help information, including data edit specifications, is available for each field on the data entry screen. The Diagnosis , Procedure, and CPT Encoders, as applicable, are accessed by double clicking the diagnosis , procedure, or HCPCS code field. The code selected is returned to the entry screen. After all cases have been entered and validated, processing is performed. Multiple processing options permit the user to process cases interactively or in a batch mode. Once processing is complete, the user can edit and re-process the case or proceed to the next. The file output option allows the user to export data. Multi-Case Entry Mode has report options of the Encoder-Plus Summary Report and Detail Report for each case.

File Input Entry Mode

File Input Entry Mode allows the user to enter and process multiple DRG/APC/ASC cases. Data is entered from a file formatted by another application or computer system. The user must specify the drive, path, and filename of the input file. After records are loaded, all input data is edited for validity and processing begins. The processing performed depends on the type of case entered. Multiple processing options permit the user to process cases interactively or in a batch mode.

The file output option allows the user to export data. File Input Entry Mode has report options of the Encoder-Plus Summary Report and Detail Report for each case.

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Case Processing Modes

Encoder-Plus For XP/Win7 can operate in three different modes: Interactive, Batch, or Command line modes. These three processing modes provide differing capabilities allowing the user to utilize Encoder-Plus in different ways.

Interactive Mode

Encoder-Plus includes a feature called Interactive Case Analysis. This powerful feature is available from all data entry modes and is the default selection from Multi-Case and File Input Entry Modes. This feature gives the user the ability to perform optimization analysis on each case. Data elements can be modified and the case can be re-processed until desired results are achieved. The Diagnosis, Procedure and CPT Encoders can be accessed during the edit process so the user can fully explore all coding possibilities. The full range of Encoder-Plus printed reports are available from Interactive Mode.

Batch Mode

Encoder-Plus provides a batch processing function for volume processing of cases. Data can input either through Multi-Case or File Input Entry Mode. Case processing then takes place with no user intervention. Output can be directed back to the screen, sent to a data file to serve as input
to another application or data repository, or printed on Encoder-Plus Reports.

Command Line Mode

Encoder-Plus DRG calculation can be invoked directly from the DOS command line. This processing mode takes advantage of the Encoder-Plus File Input and File Output functions.

Encoder-Plus For XP/Win7 will input an existing formatted data file, perform editing and DRG/APC/ASC processing, and write results to a user-specified output file without any user interaction. In this way, Encoder-Plus processing can be executed from a Batch file or set up as a Scheduled Task using Windows' Task Scheduler in conjunction with other PC applications. This option makes it possible to download formatted data from another computer, process the file through Encoder-Plus, and upload the results back to another computer for updating files. Options to this process include the selection of printed reports, selection of Automatic DRG Weight Optimization or standard DRG processing, and selection of APC/ASC output file formats.

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DRG Weight/Reimbursement Analysis

Encoder-Plus For XP/Win7 includes features for Reimbursement and DRG Weight analysis, available through all data entry modes.

Encoder-Plus offers an Automatic DRG Weight optimization function. Each diagnosis code entered will be processed as the principal diagnosis, and the code that returns the highest weight factor will be retained. Each entry mode offers the ability to edit & reprocess the discharge case. During re-edit, the user can re-order the codes and reprocess to find the highest weight.

A complete Optimization Results Tracking system helps you manage the different combinations that help you determine the correct reimbursement. Advanced Analysis Options allow you to further subdivide the data in the case and examine alternatives that may lead to other reimbursement alternatives. Optimization Detail reports and a DRG Worksheet can be printed to show the results of the analysis activity.

A DRG Check feature examines the specifics of the DRG and MDC that has been selected and will notify you if other reimbursement optimization alternatives are possible.

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Multiple Updateable DRG Weight Tables

Encoder-Plus For XP/Win7 contains a feature that allows the user to update alternate DRG Weight Tables used in the basic reimbursement calculation process. The Medicare DRG weight tables are standard and two additional updateable DRG Weight Tables are available. The individual DRG weights and average length of stay values can be updated for each DRG. The title you assign to each table can also be updated. These alternate DRG weight tables can be used for any other payer. The selection of the DRG Weight Table to be used in pricing, is made under the Blended Rate Entry/Update function.

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Encoder-Plus Reports

Encoder-Plus For XP/Win7 produces multiple types of printed reports. Details of each report are listed below. Encoder-Plus For XP/Win7 supports all Windows-supported printers.

Detail Report: Encoder-Plus will produce a detail report containing all input data and processing results. The detail report includes all codes, descriptions, DRG/APC/ASC detail results, and reimbursement amounts for the case being processed. Also edit error messages, if any, will be printed. An optional certification statement and signature block can be included for physician certification.

Encoder-Plus Summary Report: Encoder-Plus will produce a summary report from either the Multi-Case or File Input entry Modes. This report prints two lines of data for each case processed. All of the significant data elements are included. If any errors have occurred during batch type processing, detail error messages are printed.

DRG Worksheet: This report describes all of the reimbursement alternatives based on the various diagnosis code combinations explored during the optimization process. The worksheet can then be given to a physician to make the final determination of principal diagnosis based on the medical condition that occasioned the admission.

Optimization Detail Report. This report provides the detail information for each diagnosis code combination tried during the optimization process. The report shows the results of each diagnosis code being tried as the principal diagnosis and includes the DRG Weight, reimbursement, all diagnosis code, DRG and MDC descriptions.

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DRG/MDC Reference

Encoder-Plus For XP/Win7 includes an on-line reference to descriptions of all DRG’s and MDC’s (Major Diagnostic Category). This reference is available from the main menu. The desired DRG number is entered and the corresponding description is displayed in a viewing window. The user can then scroll the display to view other DRG descriptions. A search function is available to find a specific DRG.

The MDC display shows each MDC description. The display can be scrolled in order to view all MDC descriptions.

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Help

Encoder-Plus For XP/Win7 includes a comprehensive Help file to describe the features of the software.

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System Requirements

• Encoder-Plus For XP/Win7 has been designed for a single user to run on a Microsoft Windows 2000/XP/Vista/7 desktop PC.
• Administrative privileges on the system are required for installation, but Encoder-Plus runs under a regular Windows User privilege.
• Pentium IV-class PC (1 GHz or higher recommended)
• 256 MB of RAM or more (1 GB or more recommended)
• 260 MB of hard drive space required for maximum product configuration. Additional hard drive space required to store case history data (optional, but default is On).
• Designed for a screen resolution of 800x600 or 1024x768
• Mouse or other compatible pointing device

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