CUSTOM MONTHLY REPORT FORMAT

DATA TABLE 05/14/2015

[01]      ITEM CODE BEING REPORTED FROM SECONDARY SORT CHOICE

            (Example:  PROCEDURE, DIAGNOSIS, CARRIER)

[02]      INTERNAL NAME/DESCRIPTION OF SECONDARY SORT ([01] ABOVE)

            (The translation of the code, if present in a Dictionary, will print under the NAME column.)

[03]      THE TOTAL QUANTITY FOR ITEM IN [01] ABOVE

(This is a count of the number of codes named in [01].)

[04]      THE TOTAL # OF UNIQUE PATIENTS PER [01] ABOVE

(This is the unique body count of patients assigned to the code in [01].  Each Patient is counted

               once under the primary code billed only so additional codes may have zero in this column.

[05]      TOTAL CHARGES/BILLED AMOUNTS FROM ENCOUNTER

(This represents the current gross charge as found in the procedure profile as price #1.  A higher

            override charge would be used instead of the profile amount if entered during the billing.)

[06]      AVERAGE CHARGE BASED ON BILLED AMOUNT/QUANTITY

                Calculated as:                      GROSS CHARGE FOR ALL OF A CERTAIN CODE

                                                                                                   NUMBER OF THOSE CODES

[07]      TOTAL PATIENT EXPECTED AMOUNT

(Total dollars expected to be paid by patient for this procedure this month.  This amount appears

            on the patient’s statement.  This amount could include private pay, amounts not covered by

            insurance deductible, copays, co-insurance and discounts.)

[08]      TOTAL INSURANCE EXPECTED AMOUNT

(This is the portion of the charges that the insurance company is expected to pay after billing

            the charge amount.)

[09]      PERCENT OF TOTAL PATIENT EXPECTED AMOUNT

(The percentage of all expected patient dollars this month that will be received from this

            procedure.)

Calculated as:      EXPECTED PATIENT AMOUNT FOR THIS CODE ONLY          x 100

                                                         TOTAL EXPECTED PATIENT AMOUNT FOR REPORT RANGE

or

The percentage of patient expected amount per this specific

                                                item against the total patient expected for entire report.

[10]      PERCENT OF TOTAL INSURANCE EXPECTED AMOUNTS

(The percentage of all insurance dollars for this month that will be obtained from this procedure.)

Calculated as:      EXPECTED INSURANCE AMOUNT FOR THIS CODE ONLY         x 100

                                                         TOTAL EXPECTED INSURANCE AMOUNT FOR REPORT RANGE

[11]      UTILIZATION PERCENT (ALSO SHOWN AS FREQ %)

Calculated as:                      TOTAL NUMBER OF SPECIFIC ITEMS           x 100

                                                                                TOTAL NUMBER OF PATIENT VISITS

or

                                                The percentage of this procedure performed on a given

                                                unique patient.

[12]      PRODUCTION PERCENT (ALSO SHOWN AS % PROC)

Calculated as:                      TOTAL GROSS CHARGES FOR THE REPORT RANGE          x 100

                                                                     THE TOTAL GROSS FOR THIS CODE

     or

The percentage of the entire gross for all procedures represented

                                                against the gross for this particular code for the given report range.

[13]      NUMBER OF VISITS (ENCOUNTERS)

(The number of patient visits during which this procedure was performed this month.  Also, do

            not add this column for the same reason as [04].  Usually, each entry session means the patient

            left and returned for another visit.)

[14]      TOTAL DOLLAR AMOUNT OF ALL PATIENT PAYMENTS

[15]      NUMBER OF CASES PAID

[16]      TOTAL DOLLAR AMOUNT OF ALL PAYMENTS (PATIENT AND INSURANCE)

[17]      TOTAL DOLLAR AMOUNT OF ALL PATIENT AND INSURANCE ADJUSTMENTS

[18]      TOTAL DOLLAR AMOUNT OF ALL PATIENT ADJUSTMENTS

[19]      TOTAL DOLLAR INSURANCE AND PATIENT EXPECTED AMOUNTS

[20]      BALANCE OF LINE ITEM

[21]      CARRIER CODE

[22]      RESERVED FOR FUTURE USE

[23]      RESERVED FOR FUTURE USE

[24]      NUMBER OF UNIQUE ESTABLISHED PATIENTS

[25]      NUMBER OF UNIQUE NEW PATIENTS

[26]      TOTAL INSURANCE ADJUSTMENTS (CONTRACTUAL ALLOWANCE)

[27]      CONTRACTUAL TOTAL CHARGES (ORIGINAL)

[28]      NUMBER OF BOOKED APPOINTMENT SLOTS FOR DATE RANGE SELECTED

[29]      AVAILABLE APPOINTMENT SLOTS FOR DATE RANGE SELECTED

[30]      APPOINTMENT PERCENT OF SCHEDULE LOAD (0-100%)

[31]      RBRVS FEE FOR SERVICE SCHEDULE AMOUNT

[32]      CAPITATION AMOUNT WEIGHTED AGAINST USUAL FEE

[33]      APPLIED CAPITATION AMOUNT AGAINST CAP CHARGES

[34]      EXPECTED CHARGES FROM LEDGER

[35]      CHARGES PER CASE / REPORT CASE COUNTER

[36]      REPORT CASE COUNTER

[37]      AUTOMATIC ADJUSTMENT ( CHARGES - EXPECTED )

[38]      INSURANCE PAID AMOUNT

[39]      INSURANCE PAID PERCENTAGE

[40]      CONTRACTUAL ALLOWANCE

[41]      APPROVED AMOUNT

[42]      COLLECTION PERCENTAGE

[43]      PATIENT PAID AMOUNT

[44]      PATIENT PAID PERCENT

[45]      PATIENT ADJUSTMENT

[46]      PATIENT ADJUSTMENT PERCENTAGE

[47]      TOTAL CHARGES FROM CLAIM LINE ITEMS

[48]      RBRVS CALCULATED VALUE

FOR CAPITATION ANALYSIS:   [31]         FEE FOR SERVICE EQUIVALENT

                                                                                [32]         CAPITATED PAYMENTS

                                                                                [33]         WEIGHT AVERAGED CAPITATION

FOR RBRVS:                                                 [50]      WORK UNITS

                                                            [51]      WORK PERCENT

                                                            [52]      OVERHEAD UNITS

                                                            [53]      OVERHEAD PERCENT

                                                            [54]      MALPRACTICE UNITS

                                                            [55]      MAPRACTICE PERCENT

COLUMN MATHEMATICS AND FORMULAS:

[13]  +  [25]      Addition

Examples                                 [05]  -  [07]      Subtraction

                                         [11]  *  [16]      Multiplication

                                         [05]  /  [16]      Division

                                         [05]  @  [05]      Average

                                         [17] /@  [05]      Division w/Average