Calculating Patient Volume

The New Jersey Medicaid Promoting Interoperability Program defines a patient encounter as a distinct patient, date-of-service, and place-of-service combination. For example, a cardiologist who sees a patient suffering from an imminent heart attack in the morning in his office, admits the patient into the hospital for immediate surgical intervention, and then assesses the patient’s status at the hospital in the evening after the surgical intervention. In this scenario, the “patient encounter” count would be two since the patient was seen at two distinct places of service (in the Drs. office in the morning and in the hospital in the evening), even though the provider patient was seen twice on the same day.

A Medicaid patient encounter is any patient encounter (as defined above) rendered to an individual enrolled in a Medicaid fee-for-service or managed care program, regardless of whether the provider was paid by Medicaid for the encounter. Note that this definition excludes certain categories of NJ FamilyCare children and adults that are enrolled in a Title XXI Children's Health Insurance Plan (CHIP) program.

Medicaid Proxy Percentage or CHIP Proxy - Since most providers caring for Medicaid and CHIP patients are unable to differentiate their "traditional Medicaid" patients from their "CHIP" patients, the New Jersey Medicaid Promoting Interoperability Program established a unique "Medicaid Proxy Percentage" for every national provider identifier (NPI) number identified that billed the New Jersey Division of Medical Assistance and Health Services or its contracted managed care organizations for services.

The "Medicaid Proxy Percentage" is calculated by taking the percentage of claims billed by each NPI number for an entire calendar year and dividing them up between Title XIX and CHIP based on the program the patient on the claim was eligible for at the time of billing. The State needs to know this information in order to receive the appropriate federal reimbursement for the services provided. The "Medicaid Proxy Percentage" will automatically be applied to each provider's overall Medicaid encounter count once it is entered into the State's Promoting Interoperability Program Attestation Application.

Using this method in the first year of the Medicaid Promoting Interoperability Program, the numerator is the total number of Medicaid patient encounters provided in any 90 day period in the most recently completed calendar year (after the "Medicaid Proxy Percentage" is applied) and the denominator is all patient encounters provided in the same 90 day period. Below are two patient volume calculation examples:  


Provider 1

Provider 2

Initial 9 day Medicaid & CHIP Encounter Count



Medicaid Proxy Percentage



Final Medicaid Encounter Count



Total 90 Day Encounters (All Payers)



Medicaid Patient Volume Percentage



Eligible for Medicaid Promoting Interoperability Program



In the first example, the provider's initial encounter count would have returned a Medicaid Patient Volume Percentage of 60% (300 Initial Medicaid and CHIP encounters / 500 Total Encounters) and maintained eligibility after the 90% Medicaid Proxy Percentage is applied.

In the second example, the provider's initial count would have returned a patient volume of 33.3% (200 Initial Medicaid and CHIP encounters / 600 total encounters); however, applying the Medicaid Proxy Percentage brought this provider's Medicaid Patient Volume down to 16.7%, making them ineligible for the Program.

Group Practices - Providers may use a clinic or group practice’s patient volume as a proxy for their own under three conditions:

  1. The clinic or group practice’s patient volume is appropriate as a patient volume methodology calculation for the provider (each individual provider using a group practice's patient volume in an attestation MUST have at least one individual Medicaid encounter in the most recently completed calendar year).
  2. There is an auditable data source to support the group or clinic’s patient volume determination.
  3. ALL providers in the group MUST use the same patient volume calculation and individual providers CANNOT combine their individual encounters at the group with encounters with other entities in order to establish an individual patient volume. The clinic or group practice MUST use the entire practice’s patient volume and not limit it in any way. Providers may switch between individual calculation or the group/clinic patient volume in any participation year. Furthermore, if a provider within the group practice or clinic worked in both the clinic and outside the clinic (or with and outside a group practice), then the clinic/practice level determination includes only those encounters associated with the clinic/practice.

Needy Individuals - Providers that are unable to meet the necessary patient volume for eligibility using the method described above AND provided more than 50% of their encounters in a six month period in the most recently completed calendar year at a Federally Qualified Health Center may be able to use a different patient volume calculation based on "needy individuals". "Needy individuals" are defined as those enrolled in either Medicaid or CHIP, individuals furnished uncompensated care by the eligible professional, or individuals furnished services at either no cost or reduced cost based on a sliding scale determined by the individual's ability to pay. Only providers that can show they practiced predominantly in an FQHC for six months in the most recently completed calendar year are able to use this patient volume calculation method.

Additional Considerations for Calculating Patient Volume
  • "Practicing Predominantly" is when a Federally Qualified Health Center is the clinical location for 50% or more of a provider's total number of patient encounters for a six month period in the most recently completed calendar year.

  • "Needy Individuals" include: Medicaid or CHIP enrollees; patients furnished uncompensated care by the provider; or patients furnished services at either no cost or on a sliding scale.

  • Dual Medicaid and Medicare encounters CAN BE INCLUDED in the provider's patient volume calculation.

  • Eligible professionals may see their Medicaid patients at any health care place of service location/setting with the exception being eligible professionals practicing at a Federally Qualified Health Clinic (FQHC) using the “needy individual” definition; as that is applicable per the federal regulations only at FQHCs.

  • There are no restrictions on hours worked or eligible professional employment type (e.g., contractual, permanent, temporary).

  • The eligible professional must not be hospital-based, defined as 90% or more of the provider's encounters occurring at an inpatient or emergency room place of service.

  • An eligible professional is allowed to aggregate or separate patients across practice sites and places of service; however, one location that meets the applicable payment year's EHR technology incentive payment eligibility criteria (Adopt, Implement, or Upgrade or Meaningful Use) MUST BE INCLUDED in the provider's patient volume measurement.

  • An eligible professional is allowed to aggregate patients across States. The eligible professional must be able document their out-of-state patient volume.

  • All patient volume information entered into the New Jersey Promoting Interoperability Program Attestation System may be subject to audit that could result in payment recoupment.
Last Reviewed: 5/9/2018