Encoder-Plus For 95/XP
Product Pricing and License Information
Encoder-Plus For 95/XP is our flagship product and its outstanding DRG/APC and reimbursement calculation features make it an excellent choice for a variety of applications within the health care industry including:
- Claims Processing Applications
- Claim review, Compliance Auditing
- Data warehousing and data analysis
- Repricing
- Medical Review
- Medical Records, and much more
Developed in conjunction with the Insurance processing industry and Medical Records professionals, Encoder-Plus For 95/XP has the features you need to complete the job quickly and accurately.
Encoder-Plus For 95/XP™ includes the complete APC functionality and is fully compliant with the CMS Outpatient Prospective Payment (OPPS) specifications. This product is updated quarterly and will calculate APCs, DRGs, and reimbursement for any Medicare hospital in the U.S.! This functionality makes Encoder-Plus For 95/XP a very powerful tool for for claims processing applications, data warehousing and data analysis, claim review, compliance auditing, repricing applications and more. Request a Free 30-day Trial Version of Encoder-PlusFor 95/XP.
PRICERActive™ Medicare Reimbursement Components have been integrated with Encoder-Plus For 95/XP to provide stand-alone DRG calculation and detail Medicare DRG Reimbursement Calculation. Calculate an estimated Medicare reimbursement 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 95/XP includes 2 years of CMS DRG calculation and complete APC calculation functionality. Also Available: Encoder-Plus For 95/XP - Enhanced Version with 5 years of CMS DRG calculation and complete APC calculation functionality
Features of Encoder-Plus For 95/XP:
DRG Calculation
APC Assignment and Reimbursement Calculation
DRG Reimbursement Calculation System
DRG Weight/Reimbursement Analysis
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
DRG and APC Processing Modes
Multiple Updateable DRG Weight Tables
Output Options
Encoder-Plus Reports
DRG/MDC Reference
Help
Case History LogEncoder-Plus For 95/XP is simply the most versatile APC/DRG Calculation and Encoding software available today!
Encoder-Plus For 95/XP calculates the Diagnosis Related Group (DRG) according to the CMS specifications used by Medicare. DRG processing for two fiscal years is included. The patient age, sex, discharge status, diagnosis and procedure codes are used in the calculation process. The DRG, MDC, DRG Weight, DRG Average Length of Stay, and influencing codes are returned after processing. The accuracy of the DRG calculation process is a hallmark of Encoder-Plus For 95/XP.
The APC functionality for Encoder-Plus For 95/XP™ 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.
Like the inpatient system based on the Diagnosis Related Groups (DRGs), each APC has a pre-established prospective payment amount associated with it. However, unlike the inpatient system that assigns a patient to a single DRG, multiple APCs can be assigned to one outpatient record. If a patient has multiple outpatient services during a single visit, the total payment for the visit is computed as the sum of the individual payments for each service.
* Handles up tp 100 line items per claim
* Edits a claim for accuracy using full Outpatient Code Editor (OCE) specifications
and optional CMS Correct Coding Initiative (CCI) edits
* Assigns APCs
* Assigns CMS-designated service 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
95/XP™
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 will
calculate a geographically adjusted APC reimbursement for any Medicare hospital in the
U.S.
DRG Reimbursement Calculation System
Encoder-Plus For 95/XP 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. A Multi-user option allows entry of a payer ID number for each case and the ability to carry rates for multiple payers. Total charges are entered for each case and Encoder-Plus will calculate the variance between reimbursement and charges.
Optional PRICERActive™ plug-in components duplicate the calculations used by Medicare for inpatient hospital claim payment. These modules use the same hospital-specific and geographic cost factors to compute a payment amount like your Medicare intermediary. Additional cost outlier payments are computed for applicable cases. A cost outlier threshold is calculated for each case so you know where the cost boundaries are. Calculate an estimated Medicare reimbursement for any Medicare hospital in the U.S.!ICD9 Diagnosis and Procedure Encoder System
Encoder-Plus For 95/XP 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.
CPT/HCPCS Level II Encoder System
Encoder-Plus For 95/XP 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/HCPCS Level II 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/HCPCS Level II Encoder 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 CPT/HCPCS Level II Encoder contains a Keyword Index Search feature. This function helps locate the desired code. Keywords can be added to the Index by the user for a customized system. Keyword Inquiry facility displays available keywords. Direct access to CPT codes is also available.
The CPT/HCPCS Level II Encoder contains features for the addition and deletion of local codes. With this feature, the system can be updated to contain user-specific information.
The INDEX SEARCH feature allows the user to more closely locate the desired CPT code. Up to three keywords can be entered to search on. All or part of the keyword may be entered (up to 20 chars). The Index search feature will display the CPT codes matching the keyword criteria. From this point, Additional Information displays are available to help the user make the final code determination.
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.
Other facilities are also available:
Add Local Codes: This feature allows the user to add local codes to the CPT/HCPCS Level II Encoder for future access. Typically, different regions of the country have different local standards. This feature allows Encoder-Plus to be adaptable to all situations.
Delete Local Codes: This feature allows the user to delete local codes when they become outdated or obsolete.
Keyword Inquiry: If you are unsure of the available keywords, this display will show you.
Add New Keyword: With this facility you add keywords to customize or enhance the Index Search capability.
The Encoder-Plus For 95/XP 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 CPT case data entry screens. By placing the cursor on the CPT 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 data entry screen also has an encoder for CPT Modifiers that is available when the cursor is positioned on the modifier field. The CPT code must first be entered before the modifier list can be accessed.
Encoder-Plus For 95/XP 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.
Encoder-Plus For 95/XP 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. The effect of this data validation is to help the user produce more accurately coded cases which will be paid in a more timely manner.
For a CPT case, patient age, sex, service from date and at least one CPT code are required. All CPT codes are validated against internal tables.
Encoder-Plus For 95/XP includes an error processing subsystem to help resolve difficult edit errors. If an error occurs that cannot be immediately resolved, it can be written to an internal error file for later resolution. This facility saves re-keying data and serves as a tracking mechanism for cases in process. Cases can be recalled from the error file to be re-processed after further research or verification is performed. Case profiles can be printed and unwanted cases can be deleted from the error file.
Encoder-Plus For 95/XP incorporates multiple data entry to provide flexibility and adaptability to many environments. These data entry modes are summarized below:
DRG Single Case Entry Mode
Single Case Entry Mode allows the user to enter and process a single patient discharge. 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 Encoder and Procedure Encoder is accessed by double clicking the diagnosis or procedure code field. The diagnosis/procedure code selected is returned to the entry screen. After data has been entered and validated, DRG processing is performed. Processing is performed in Interactive Mode. DRG analysis options include Automatic DRG Weight Optimization or standard DRG processing. Once DRG processing is complete, the user can edit and re-process the case or proceed to the next. The Diagnosis and Procedure Encoders can be accessed during re-edit. From Single Case Entry Mode the user can print a Physician Attestation Form for the completed case.
DRG Multi-Case Entry Mode
Multi-Case Entry Mode allows the user to enter and process multiple patient discharges. 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 Encoder and Procedure Encoder is accessed by double clicking the diagnosis or procedure code field. The diagnosis/procedure code selected is returned to the entry screen. After all cases have been entered and validated, DRG processing is performed. Multiple processing options permit the user to process cases interactively or in a batch mode. DRG analysis options include Automatic DRG Weight Optimization or standard DRG processing. Once DRG processing is complete, the user can edit and re-process the case or proceed to the next. The Diagnosis and Procedure Encoders can be accessed during re-edit. The file output option allows the user to export data. Multi-Case Entry Mode has report options of the Encoder-Plus Summary Report and Physician Attestation Forms for each case.
APC Single Case Entry Mode
Single Case Entry Mode allows the user to enter and process a single APC case. Data is entered via the screen and is edited for validity via the full set of Outpatient Code Edits (OCE). Help information, including data edit specifications, is available for each field on the data entry screen. The CPT/HCPCS Level II Encoder is accessed by double clicking the CPT code field. The code/modifier selected is returned to the entry screen. After data has been entered and validated, reimbursement calculation is performed. Processing is performed in Interactive Mode. A results display screen will show all CPT codes that have been entered, the resulting APCs along with their descriptions. The display can be toggled to show the reimbursement amounts for each code. Once all processing is complete, the user can edit and re-process the case or proceed to the next. The CPT/HCPCS Level II Encoder can be accessed during re-edit. From Single Case Entry Mode the user can print a Detail Report/Attestation Form for the completed case.
APC Multi-Case Entry Mode
Multi-Case Entry Mode allows the user to enter and process multiple APC cases. Data is entered via the screen and is edited for validity via the full set of Outpatient Code Edits (OCE). Help information, including data edit specifications, is available for each field on the data entry screen. The CPT/HCPCS Level II Encoder is accessed by double clicking the CPT code field. The code/modifier selected is returned to the entry screen. After all cases have been entered and validated, reimbursement calculation is performed. A results display screen will show all CPT codes that have been entered, the resulting APCs along with their descriptions. The display can be toggled to show the reimbursement amounts for each code. Once all processing is complete, the user can edit and re-process the case or proceed to the next. The CPT/HCPCS Level II Encoder can be accessed during re-edit. 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/Attestation Form for each case.
File Input Entry Mode
File Input Entry Mode allows the user to enter and process multiple DRG or APC cases. Data is entered from an ASCII 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 whether the case is marked as APC or a DRG case. Multiple processing options permit the user to process cases interactively or in a batch mode.
For DRG cases, DRG analysis options include Automatic DRG Weight Optimization or standard DRG processing. Once DRG processing is complete, the user can edit and re-process the case or proceed to the next. The Diagnosis and Procedure Encoders can be accessed during re-edit.
The file output option allows the user to export data. File Input Entry Mode has report options of the Encoder-Plus Summary Report and Physician Attestation Forms for each case.
Encoder-Plus For 95/XP 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 DRG & APC Multi-Case and File Input Entry Modes. This feature gives the user the ability to perform optimization analysis on each discharge case. Data elements can be modified and the case can be re-processed until desired results are achieved. This unique feature along with Automatic DRG Weight Optimization gives the user a powerful set of tools to maximize the DRG reimbursement. 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 processing of large numbers of DRG or APC cases. Data can input either through Multi-Case or File Input Entry Mode. DRG processing or CPT reimbursement calculation then takes place with no user intervention. Output can be directed back to the screen, printed on the Encoder-Plus Summary Report, or sent to an ASCII file to serve as input to another PC application. This data file can also be uploaded to a mini or mainframe computer. Physician Attestation forms can also be printed for each case.
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 will input an existing formatted data file, perform editing and DRG calculation or CPT 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 DOS Batch file 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 to patient files. Options to this process include the selection of printed reports and selection of Automatic DRG Weight Optimization or standard DRG processing.
DRG Weight/Reimbursement Analysis
Encoder-Plus For 95/XP includes features for Reimbursement and DRG Weight analysis, available through all data entry modes. This process will assure the correct reimbursement.
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. Automatic mode will not optimize to a DRG of 468 (OR Proc. unrelated to principal diagnosis). 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.
Multiple Updateable DRG Weight Tables
Encoder-Plus For 95/XP contains a feature that allows the user to update alternate DRG Weight Tables used in the 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 Medicaid, CHAMPUS, private insurance or any other payer. This feature provides great flexibility for reimbursement calculation among many payers. The selection of the DRG Weight Table to be used in pricing, is made under the Blended Rate Entry/Update function. This feature is only available under the Multi-User Pricing Option.
Encoder-Plus For 95/XP offers multiple Output Options for maximum flexibility. Processing results can be directed back to the screen, printed, or formatted into an ASCII file that can be passed to other applications or even uploaded to mini or mainframe computers.
From Interactive Mode for a DRG case, a detail display of processing results including diagnosis/procedure codes, code descriptions, DRG, DRG Weight, and DRG description is presented. This detail display helps the user assure that ICD9 codes selected and results achieved are accurate.
The screen output from Batch Mode displays a single line for each case processed. Included are patient account, name, diagnosis/procedure codes used, the resulting DRG and DRG Weight. The display will scroll up the screen as cases are processed. Edit error messages, if any, will be displayed on screen.
The results display from Interactive mode for a CPT case shows the CPT codes, code descriptions and reimbursement data. The display can be toggled to display the detail reimbursement amounts for each CPT code.
Printed reports are available for both DRG & CPT cases from all entry and processing modes. Data File Output, as mentioned above, is available only from Multi-Case and File Input Entry Modes.
Encoder-Plus For 95/XP produces multiple types of printed reports. Details of each report are listed below. Encoder-Plus For 95/XP supports all Windows-supported printers.
Deatil/Attestation Form: Encoder-Plus will produce a detail report containing all input data and processing results. The attestation form includes descriptions of all diagnosis and procedure codes along with DRG and MDC descriptions. A separate report layout is produced for a CPT case that will show all CPT codes and descriptions. A certification statement and signature block are 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.
Encoder-Plus For 95/XP 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.
Encoder-Plus For 95/XP includes a comprehensive Help file to describe the features of the software.
Encoder-Plus For 95/XP 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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