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DYNAMIC CHARGEMASTER
STRATEGIES AND
EMERGING TRENDS
Glenda J Schuler, RHIT, CPC, COC
Vice President, Revenue Cycle Solutions
The information in this presentation is an overview and does not
contain all information necessary or available, and although we have
tried to include accurate and comprehensive information in this
educational presentation, please remember it is not intended as legal,
tax, business, financial or other professional advice.
Furthermore, this educational presentation is not inclusive of all of the
updates, changes, rules and citations impacting your hospital, health
system, clinic and/or department.
The information contained in this presentation has been prepared in
good faith. However, no representation or warranty, expressed or
implied, is made as to the accuracy, correctness, completeness or
adequacy of any statement, commentary, opinions or other information
contained in this presentation.
2
Disclaimer
3
Chargemaster & Reimbursement
Strategies
Data Mining – what internal
reports are key
Chargemaster automated charge
capture processes
Chargemaster Maintenance and
Updates
Tools to Stop Revenue Loss
“If hospitals improve financially, it will most
likely be due to improved operations rather
than increased investment returns.”
Fitch IBCA, Duff & Phelps
www.fitchratings.com
Financial Forecasts
4
What is a charge description master (CDM)?
Menu of all services and
supplies/implants/pharmaceuticals provided by the
facility, usually listed by department
Charge Description Master- What Is It?
5
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
Common Information In The Chargemaster
6
Multiplier, Unit of Service,
Can also reside in the
CDM
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
• Hospital‐specific
• Revenue centers vs. cost centers
• Typically equates to general ledger (GL) number
• Link between department and charge code for revenue and usage reporting
• Dept # can be included in charge code # but varies by system, e.g., Epic, Cerner, Meditech, McKesson
Common Information In The Chargemaster
13
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
• Unique line‐item identifier
• Can include CPT/HCPCS #
• May or may not be department specific
• Interface between order entry and billing
May be also known as:
• Charge Code
• Line‐item number
• Financial Item Number (FIN)
Common Information In The Chargemaster
8
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
• Limitations based on Field
length restraints
• Pros and cons of description
standardization
• Clinically relevant descriptions
• Represents CPT/HCPCS
descriptions
• Patient friendly descriptions
• Supports hard‐coded
CPT/HCPCS
Common Information In The Chargemaster
9
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
• Mortuary preparation charge
• Cadaver bags
• Enema can & tubing
• TB skin tst results pos
• Deodorant colostomy
• Tonsil wires
• Booklet-brain attack
• Mitt wash pink
Common Information In The Chargemaster
10
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
With increased transparency pressure, there are a variety of different approaches to annual rate changes among hospitals around the country
If a peer facility elects to decreased rates by 1 percent each year while your hospital increased by 5 percent, your hospital’s rates would be about 35 percent higher than the peer in five years
Common Information In The Chargemaster
11
• Hospitals are increasingly challenged with pricing
pressures, which has resulted in a variety of strategies
• While many hospitals are increasing rates well above
that average, a large portion are making strategic
decisions to lower overall rates of change
Pricing Strategies
12
In the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28169), we reminded hospitals of their obligation to comply with the provisions of section 2718(e) of the Public Health Service Act. We appreciate the widespread public support we received for including the reminder in the proposed rule. We reiterate that our guidelines for implementing section 2718(e) of the Public Health Service Act are that hospitals either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or their policies for allowing the public to view a list of those charges in response to an inquiry
Pricing Strategies
13
Patient Friendly Descriptions
14
Gross Revenue – Analysis of Charge Structure
15
Mcare Reimb
Cost Tiers
Supplies
Mark-up
Average
Sample
Size
(Hospitals)
261
< $5.00 5.30 1.75 to 24.57
$5.01 - $10.00 5.25 1.75 to 21.70
$10.01 - $20.00 4.86 1.75 to 21.70
$20.01 - $50.00 4.57 1.75 to 18.60
$50.01 - $100.00 4.14 1.50 to 13.00
$100.01 - $500.00 3.68 1.25 to 10.92
$500.01 - $1,000.00 3.19 1.25 9.73
> $1,000.01 2.82 1.25 to 9.73
Supplies Mark-
up Range
Pricing Strategies - Supplies
16
Sample of mark-up formula used for medical/surgical supplies:
Implantables are often marked up “costs” x 4
Pricing Strategies - Procedures
Methodology #1 Methodology #2
Medicare APC Rates◦ Multiply x 2 – 4
◦ Defensible
◦ Difficult to price procedures
that are “packaged” by Mcare
Cost Strategy◦ Overhead costs
◦ Salaries for staff
◦ Routine supplies
◦ Time involved
Apply mark-up formula to
obtain charge
17
Pricing Strategies - Procedures
Methodology #3 Methodology #4
Set charges at 50th - 75th
percentile of facilities in
geographic area
Purchase MedPar Data◦ Obtain commercial claim
data
Strategic Price Analysis◦ Does include selected
facility pricing data
◦ Includes commercial payer contract considerations
◦ Sometimes across-the-board price increases not best return, selective procedure prices can increase or decrease
18
• Average Wholesale Price (AWP)
• Average Sales Price (ASP)
• Acquisition costs – apply mark-up formula
• Watchful for self-administered drugs
• Over-the-counter medications
• Source for Patient dissatisfaction
Pricing Strategies - Pharmacy
19
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
Claims processing
For outpatient claims, certain revenue codes require CPT/HCPCS
Payment—reimbursement
Regulatory requirements
Decision to hard-code or soft-code
Recommend charge to be reported for each CPT or HCPCS code reported
Common Information In The Chargemaster
20
• Department #
• Item #
• Internal description
• Patient-friendly description
• Price
• CPT/HCPCS code
• Revenue code
The intent was to describe:
• What was performed versus where it was performed:
• In OPPS, Medicare does not recommend reportable revenue code
• Report where the cost resides/procedure performed
• May be payer-specific
• Professional vs Technical
Used for:
• Organization of charge data
• Pipeline to the cost report
Common Information In The Chargemaster
21
22
025X Pharmacy027X Medical supplies/devices
Revenue Code 0278, Implantables do require HCPCS by some commercial payers
037X Anesthesia0390 Blood storage/processing071X Recovery room0762 Observation0942 Education & training services
Revenue Codes Not Requiring a CPT/HCPCS Code for Billing
Revenue Code Selection
• Uniform Code Editor:
• National revenue code recommendation
• Medicare states:
• Facility can report the procedure using the revenue code that represents where the procedure was performed (costs follow revenue)
Colonoscopy RC 0360 Operating room
Colonoscopy RC 0750 GI laboratory
Colonoscopy RC 0761 Treatment room
Colonoscopy RC 0450 Emergency room
23
24
UB-04 Claim Form
Chargemaster data
reported in this
section of the claim
form
FL #42, Revenue Code
25
0324
Revenue Codes Requiring HCPCS
(Partial List)
26
FL 43—Description
27
0324 Radiology Chest X-ray
• The hospital’s description of the service provided
• Usually reflects the revenue code description:
• Pharmacy
• Supplies
• X-ray
• CT scan
• Emergency room
Form Locator 43—Description
28
FL 44—HCPCS/Rates
29
0324 Radiology Chest X-ray 71020
• The CPT or HCPCS code that reflects the service being provided:
• CPT —Five-digit numeric defined by AMA
• HCPCS—Five-digit alphanumeric defined by CMS
• Modifiers also go in this field:
• Two-digit number, letters, or alphanumeric that provides additional information about the CPT or HCPCS code it is reported with:
• RT- Right LT- Left 91- Repeat lab test
• UB-04 accommodates four modifiers
• A total of 13 digits
FL 44—HCPCS
30.
FL 45—Service Date
31
0324 Radiology Chest X-ray 71020 032517
• The date the service was provided
• Is specific to each revenue code reported on the claim
• This date must coincide with the dates in FL 6 Statement
covers period
• Will determine payment rate related to the quarterly
updates in APC program
FL 45—Service Date
32
FL 46—Service Units
33
0324 Radiology Chest X-ray 71020 032517 1
.
• The number of times the service was provided.
• Service codes typically are a 1—one ER visit, one Chest
X-ray
• Supplies could be numerous—if six different supply items
were used, then a unit of 6 would be reported with
revenue code 027X
• Pharmacy is often more than 1 unit
• Time-based procedures are typically more than 1 unit
FL 46—Service Units
34
• Effects on reimbursement:
• HCPCS code J9065 is Cladribine per 1 mg
• National reimbursement is $20.91
• Physician orders 5 mg therefore 5 units of J9065 should
be reported with a resulting reimbursement of $104.45
• Revenue Code 0636
FL 46—Service Units
35
FL 47—Total Charges
36
0324 Radiology Chest X-ray 71020 032517 1 75 00
• Charges per service reported
• The total charges should be added up at the bottom of the
field and be associated with revenue code 0001
• Charges are set by the facility
FL 47—Total Charges
37
FL 48—Noncovered Charges
38
0324 Radiology Chest X-ray 71020 032517 1 75 000637 Pharmacy-Self Admin 032517 3 15 75A9270GY
Should reflect charges incurred by the
facility that you know are not covered
by Medicare:
◦ Self-administered drugs (RC 637)
◦ Patient convenience items (RC 99X)
◦ Items not meeting medical necessity
(Modifiers based on obtaining ABN)
FL 48—Noncovered Charges
39
• Who maintains the CDM?
• Revenue Integrity
• Clinical assistance
• Coding contribution
• Billing input
• Financial involvement
• Compliance support
Close communication with
clinical departments
Audit to determine what
was ordered, performed
and billed is consistent
Who Maintains the Chargemaster-The Team
40
Initiate
Revenue Integrity-Managing the Chargemaster
Workflow
41
Requests for procedure, supply, pharmaceuticals received
from clinical departments
Quarterly and annual updates
Disseminate regulatory updates
Continual and open communication with ancillary
departments, PFS and HIM
Initiate Audits
Revenue Integrity-Managing the Chargemaster
Workflow
42
Confirms all charge lines appropriately utilized
Periodically focuses on specific departments for charge
capture accuracy and provides education as necessary
Reviews frequency of CCI edits and/or claim rejections from
PFS
Validates projected revenue for clinical areas
Retains compliance for governmental billing
Initiate Interface
IntegrityAudits
Revenue Integrity-Managing the Chargemaster
Workflow
43
Charge Capture Chargemaster
Chargemaster Coding
Coding Billing
Initiate AuditsInterface
IntegrityEducation
Revenue Integrity-Managing the Chargemaster
Workflow
44
Ancillary staff relies on Revenue Integrity for answers to
questions on how to charge, reimbursement questions and
operational options
Provides education for annual coding and reimbursement
updates
• Who maintains the CDM?
• Revenue Integrity
• Clinical assistance
• Coding contribution
• Billing input
• Financial involvement
• Compliance support
Engage clinical department
expertise to review specific
chargemasters
More minds are better than
one
Department’s area of
business
Who Maintains the Chargemaster-The Team
45
• Who maintains the CDM?
• Revenue Integrity
• Clinical assistance
• Coding contribution
• Billing input
• Financial involvement
• Compliance support
Determine what
procedures should be hard-
coded/soft-coded
Assignment of modifiers
Work NCCI edits
Review MUE edits
Assigns modifiers, e.g.
modifier -59
Who Maintains the Chargemaster-The Team
46
Chargemaster vs. HIM Coding
Chargemaster coding or HIM coding (“hard” vs. “soft” coding)?-
- Surgery - Emergency room - Endo suites
- Clinics - Cardiac cath -Interv. radiology
HIM typically codes major surgery (CPT 10000 — 69999)
CDM Number Billing Description G/L Key CPT R.C.
43000108 I&D SUBCUT ABSC SIMP 630 10060 450
43000207 I&D SUBCUT ABSC COMP 630 10061 450
43000306 I&D PILONIDAL ABSC 630 10080 450
70210034 MAJOR SURG LEVEL 1/1ST HR 702 - 360
70220033 MAJOR SURG LEVEL 1 EA ADDL 15 MIN 702 - 360
70230032 MAJOR SURG LEVEL II /1ST HR 702 - 360
70240031 MAJOR SURG LEVEL II EA ADDL 15 MIN 702 - 360
70250030 MAJOR SURG LEVEL III/1ST HR 702 - 360
70260039 MAJOR SURG LEVEL III EA ADDL 15 MIN 702 - 360
70210042 MINOR SURG CANCEL CASE 702 - 360
47 .
Chargemaster vs. HIM Coding
48
Manual Manipulation of UB-04 Claim Data
49
Reimbursement . . .
Screening and Diagnostic procedure on same claim form should
generate CCI edits
• Share chargemaster with HIM coding staff:
• Eliminates duplicate work
• Avoids potential double reporting
• Ensures continuity of reporting procedures and proper revenue
• Create “Who Codes For What” Policy
• Specific for each department
• CPT Code range
• Include HCPCS
Coding Decisions
50
• Who maintains the CDM?
• Revenue Integrity
• Clinical assistance
• Coding contribution
• Billing input
• Financial involvement
• Compliance support
Communication remains
open for payer denials
Revenue Code rejections
Non-covered procedures
Inpatient/Outpatient
Who Maintains the Chargemaster-The Team
51
• Who maintains the CDM?
• Revenue Integrity
• Clinical assistance
• Coding contribution
• Billing input
• Financial involvement
• Compliance support
Contract Management
communicates details
Carve-out specific
revenue codes
Coverage policies
Who Maintains the Chargemaster-The Team
52
• Who maintains the CDM?
• Revenue Integrity
• Clinical assistance
• Coding contribution
• Billing input
• Financial involvement
• Compliance support
Compliance kept in loop for any billing or coding issues identified
Review RAC initiatives
Review OIG Work Plan
Review OIG audits
Regulatory expertise
Responsibilities can include charge auditing, process improvement and reimbursement auditing independent of RI Dept
Who Maintains the Chargemaster-The Team
53
Identified Revenue Opportunities Easily Recognized By Analyzing Revenue and Usage Data
54
Procedures with One-to-One Reporting
Speech-Pathology Procedure
Radiology Procedure
• CPT 92611 Motion
fluoroscopic evaluation of
swallowing function by cine
or video recording
•
• 74230 Swallowing function,
with cineradiography/
video-radiography
•
55
Speech Pathology Evaluation and Fluoroscopy
56
SIM Code FIM Code SIM Description
Primary
Price
IP
Volume
2016
OP
Volume
2016
Total
2016
Volume
Default
CPT/HCPCS
Code
15155 792015155 ST VIDEO SWALLOW STUDY $350.00 854 371 1225 92611GN
42307 770042307 RA MODIFIED BARIUM SWALLOW $1,155.00 648 371 1019 74230
TOTAL 206 206
Calculations for Gross Revenue Opportunity Identified for Inpatients
Radiology Missed 206 Videography Procedures, each with a charge of $1,155
$1,155 x 206 = $237,930
Speech Pathology Evaluation and Fluoroscopy
• Net Reimbursement Quantification can be a challenge:
57
Payer How Paid Payer Mix Net Reimbursement Oppor
Medicare MS-DRG 49% No Add'l Net Reimbursement
Medicaid Case Rate 15% No Add'l Net Reimbursement
BC 5% Charges 10% $1,190.00
UHC 8% Charges 5% $952.00
Self Pay 3% $3,570.00
Other 18% No Add'l Net Reimbursement
TOTAL $5,712.00
• CPT 36600 Withdrawal of arterial blood
• Status Indicator Q1
• Reimbursement is $91.18
• Requires more effort and risk than a simple
venipuncture (which is paid separately under clinical
laboratory fee schedule)
Respiratory Therapy-Arterial Collections
58
Respiratory Therapy-Arterial Collections
59
Arterial Puncture reported by Respiratory Therapy
Arterial Blood Gas Analysis performed by Lab
One-to-one correlation except when drawing
specimen from established arterial line
Revenue Code 920 for CPT®
36600
Dept Chg # Description Charge
IP
Volume
OP
Volume
Total
Volume
CPT
Code
Resp Ther 780015509 THERAPIST ABG DRAW $135.00 6260 344 6604 36600
Lab 753037161 VENOUS BLOOD GASES $223.00 221 20 241 82803
Lab 755010058 BLOOD GAS POINT OF CARE $223.00 2950 19 2969 82803
Lab 753037153 ARTERIAL BLOOD GASES $223.00 4151 305 4456 82803
Respiratory Therapy-Arterial Collections
60
Dept Chg # Description Charge
IP
Volume
OP
Volume
Total
Volume
CPT
Code
Resp Ther 780015509 THERAPIST ABG DRAW $135.00 6260 344 6604 36600
Lab 753037161 VENOUS BLOOD GASES $223.00 221 20 241 82803
Lab 755010058 BLOOD GAS POINT OF CARE $223.00 2950 19 2969 82803
Lab 753037153 ARTERIAL BLOOD GASES $223.00 4151 305 4456 82803
TOTAL 7101 324 7666
Missed Procedures 1062
Not all specimen collections are obtained via arterial puncture. Nursing/Respiratory
Therapists may collect from an established arterial catheter, see CPT 37799
If the missing procedures shown above represent the specimen collections obtained from an
established arterial catheter, we need to include those procedures in the analysis
Respiratory Therapy-Arterial Collections
61
To quantify gross revenue for the above missing specimen collections:
Missing procedures 542 x Charge of $135.00 = $73,170
Dept Chg # Description Charge
IP
Volume
OP
Volume
Total
Volume
CPT
Code
Resp Ther 780015509 THERAPIST ABG DRAW $135.00 6260 344 6604 36600
Lab 753037161 VENOUS BLOOD GASES $223.00 221 20 241 82803
Lab 755010058 BLOOD GAS POINT OF CARE $223.00 2950 19 2969 82803
Lab 753037153 ARTERIAL BLOOD GASES $223.00 4151 305 4456 82803
TOTAL 7101 324 7666
Nursing
Svs 638456451 SPECIMEN COLL EXIST CATH $223.00 520 520 37799
MISSING PROCEDURES 542
Respiratory Therapy – Other Procedures
• Cardiopulmonary Resuscitation
• How many charged by department versus charged
by emergency department
• Any other department have access to charge lines
to also charge?
• Reportable one time per episode
• Reportable by a single department
62
• The professional follow-up services are typically captured in the
physician’s global period and not separately reportable. However, for
the technical charges, the hospital does not have a global or follow-up
period and each patient encounter may be separately charged. Based
on previous fiscal year’s data the facility has the gross revenue
opportunity as shown below:
Actual Chargemaster Audit Results
63
Emergency Room
• 99281 57,180
• 99282 86,311
• 99283 204,218
• 99284 73,881
• 99285 75,774
• 99291 4,360
• Total 501,724
Bell Curve-Technical Component E.R.
0
50000
100000
150000
200000
250000
300000
Evaluation and Management Codes
E.R
. V
isit
s9928599284992839928299281
64
Emergency Room: Inappropriate Bell Curve
65
0
2,000
4,000
6,000
8,000
Series1 2,258 5,893 1,828 386 28 42
1 2 3 4 5 699281 99282 99283 99284 99285 99291
ER Volume
YTD OP
Qty Var. Projected
Avg
Charge
Additional
Revenue Proj
99281 2,258 -1,500 758 $75 -$112,500
99282 5,893 -4,000 1,893 $139 -$556,000
99283 1,828 4,200 6,028 $209 $877,800
99284 386 950 1,336 $345 $327,750
99285 28 250 278 $378 $94,500
99291 42 100 142 $807 $80,700
10,435 0 10,435 $712,250
Emergency Room: Projected Gross Revenue
66
• Hospitals are required to use HCPCS code 99291 to report
outpatient encounters in which critical care services are
furnished. The hospital is required to use HCPCS code
99291 in place of, but not in addition to, a code for a
medical visit or for an emergency department service.
• CPT 99291 Critical care, evaluation and management of
the critically ill or critically injured patient; first 30-74
minutes
• CPT 99292 Critical care, evaluation and management of
the critically ill or critically injured patient; each additional
30 minutes (List separately in addition to code for primary
service)
Emergency Room-Critical Care
67
Charge
Code Charge Description
Rev
Code Price
HCPCS
CODE
27810F CLSD TX BIMAL ANKL FX W MANIP 450 $253.10 27810
27816F CLSD TX TRIMAL ANKL FX WO MANIP 450 $253.10 27816
27818F CLSD TX TRIMAL ANKL FX W MANIP 450 $253.10 27818
27830F CLSD TX PROX TBF DSLC WO ANESTH 450 $253.10 27830
27842F CLSD TX PROX TBF DSLC W ANESTH 450 $1,092.10 27842
27840F CLSD TX ANKLE DISLOC WO ANESTH 450 $253.10 27840
30905F CONTROL OF NOSEBLEED 450 $258.55 30905
30906F REPEAT CONTROL OF NOSEBLEED 450 $258.55 30906
31500F INSERT EMERGENCY AIRWAY 450 $524.75 31500
31505F LARYNGOSCOPY;INDIRECT DX 450 $146.20 31505
31511F REMOVE FOREIGN BODY LARYNX 450 $146.20 31511
31575F LARYNGOSCOPY;FLEX F/O DX 450 $63.30 31575
Emergency Room-Hard Coded CPT Codes
68
Charge
Code Charge Description
Rev
Code Price
HCPCS
CODE
2307867 ER PROC ORTHO LEVEL 1 450 $350.00
11286533 ER PROC ORTHO LEVEL 2 450 $375.00
20265199 ER PROC ORTHO LEVEL 3 450 $400.00
29243865 ER PROC INTEGUMENTARY LEVEL 1 450 $175.00
38222531 ER PROC INTEGUMENTARY LEVEL 2 450 $275.00
47201197 ER PROC INTEGUMENTARY LEVEL 3 450 $375.00
56179863 ER PROC OCCULAR LEVEL 1 450 $100.00
65158529 ER PROC OCCULAR LEVEL 2 450 $125.00
74137195 ER PROC OCCULAR LEVEL 3 450 $150.00
83115861 ER PROC DIGESTIVE LEVEL 1 450 $300.00
92094527 ER PROC DIGESTIVE LEVEL 2 450 $350.00
92184293 ER PROC DIGESTIVE LEVEL 3 450 $375.00
Emergency Room-HIM Assigned CPT Codes
69
Emergency Room-Procedure Charge Methodologies
Chargemaster-Hard Coded HIM-Assigned CPT Codes
• Each procedure contains individual charge line with charge
• Easier to audit charge capture process
• Charge capture processes often easier
• Increased gross revenue when converting to this model
• Charge platform more generic
• Charges may be below the Medicare APC amount
• Often have missed charges if multiple procedures performed
• HIM-assigned CPT codes may be reported with incorrect procedure charge line
70
Clinic Encounters – Commercial vs Medicare
Commercial Payers Incl Medicaid Medicare
Description
OP
Volume
Clinic Visit Level 1 New/Est 12530
Clinic Visit Level 2 New/Est 1320
Clinic Visit Level 3 New/Est 15
Clinic Visit Level 4 New/Est 0
Clinic Visit Level 5 New/Est 0
TOTAL 13865
• G0463, Hospital outpatient
clinic visit for assessment
and management of a
patient
• A single charge for any
Medicare encounter fails to
show resource
consumption and costs
71
Imaging Components
• Radiology S&I RC 320
• CT guidance RC 350
• MRI guidance RC 610
• Ultrasound guidance RC 402
Surgical components
• One-to-one relationships
• Complex cases
• Revenue code 360/361 or RC 320, 350, 610 or 402
Interventional Radiology
72
Interventional Radiology
73
CPT Description 2014 2015 2016 Charge APC
73040 Shoulder arthrography 150 31 85 $280
23350 Injection Shoulder arthrog 113 16 60 $237 Status "N"
Missed Procedures 37 15 25 Status "N"
Missed Gross Revenue $8,769 $3,555 $5,925 $18,249 Status "N"
CPT Description 2014 2015 2016 Charge APC
73580 Knee arthrography 0 0 14 $265
27370 Inj knee arthrography 0 0 0 $200 Status "N"
Missed Procedures 14 Status "N"
Missed Gross Revenue $0 $2,800 $2,800 Status "N"
CPT Description 2014 2015 2016 Charge APC
73525 Hip arthrography 31 0 43 $188
27095 Inj hip arthrography 0 0 18 $202 Status "N"
Missed Procedures 31 25 Status "N"
Missed Gross Revenue $6,262 $5,050 $11,312 Status "N"
Three Years Gross Revenue Opportunity $32,361
Interventional Radiology
74
CPT Description 2014 2015 2016 Charge APC
74455 Urethrocystography voiding 146 55 95 $217
74430 Cystogram min 3 views 62 0 77 $205
51600 Inj urethro voiding 77 26 85 $241 Status "N"
Missed Procedures 131 29 87 247 Status "N"
Missed Revenue $31,571 $6,989 $20,967 $59,527 Status "N"
CPT Description 2014 2015 2016 Charge APC
74450 Urethrocysto retrograde 28 25 26 $242
51610 Inj Urethrocysto retro 0 0 0 $200 Status "N"
Missed Procedures 28 25 26 79 Status "N"
Missed Revenue $5,600 $5,000 $5,200 $15,800 Status "N"
• OCE Edit # 43
• Transfusion or blood product exchange without
specification of blood product
• Generated when
• A blood transfusion or exchange is coded but no
blood product is coded
• May occur when blood product charges posted on
wrong date of service or incorrect patient encounter
Blood Administration, OCE Edit Billing Issues
75
Create a backward edit so that:
• Outpatient:
• When a blood product is coded and reported on the claim, a transfusion or exchange must also be on the claim
• Inpatient:
• When revenue code 38X or 390 is on the claim, expect to also see revenue code 391 also reported
• Accuracy of revenue code assignment in chargemaster is important
Blood Administration, OCE Edit Billing Issues
76
Blood Administration Analysis
77
Chg # Charge Description Charge
IP
Utilization
OP
Utilization
Total
Util
CPT
Code
757016671 PLT PHER LR QUAD IRR $1,085.00 1 0 1 P9037
757011353 CRYOPRECIPITATE 5 UNIT POOL $640.00 44 0 44 P9012
757023668 LRPC $451.00 1822 821 2643 P9016
757023189 PLATELETS PHERESIS LEUKORED REDUC$1,425.00 356 135 491 P9035
757023205 PLATELETS PHERESIS LEUKOCYTES RE $1,830.00 61 20 81 P9037
757016669 LRPC QUAD IRRAD $566.00 1 0 1 P9040
757023221 LRPC IRRAD $698.00 87 18 105 P9040
757022850 FRESH FROZEN PLASMA $167.00 1115 503 1618 P9059
TOTAL 3487 1497 4984
On “Average”, each transfusion service averages approximately two blood
products per administration
Calculation then demonstrates the facility should have approximately 1,743
transfusions for inpatients and 748 transfusion charges for outpatients
Blood Administration Analysis
78
Chg # Charge Description Charge
IP
Utilization
OP
Utilization
Total
Util
CPT
Code
608013282 NB BLOOD ADMINISTRATION $1,200.00 3 0 3 36430
785013029 BLOOD ADMINISTRATION $1,200.00 0 0 0 36430
100010047 BLOOD ADMINISTRATION $1,200.00 11 472 483 36430
730012453 BLOOD ADMINISTRATION $1,200.00 2 0 2 36430
TOTAL 16 472 488
It appears the facility missed 1,727 administration charges for inpatients and
276 charges for outpatient encounters
Blood Administration Analysis
79
Charge Description
IP
Utilization
OP
Utilization Total Util
Reported Blood Products 3487 1497 4984
Two products per administration 2 2 2
Reportable Transfusion Procedure 1743.5 748.5 2492
Reported Transfusion Services 16 472 488
Missed Transfusion Procedures 1727.5 276.5 2004
Charge for Transfusion Procedure $1,200 $1,200 $1,200
Gross Revenue Opportunity $2,073,000 $331,800 $2,404,800
Charge Capture Processes and Use of Technology As A Helpful Tool
80
• There are different ways that charges are reported
• Charge to drop as soon as an order is documented
• When drug or supply removed from Pyxis or Omnicell
Drug charge drops upon administration
• Charges will often not drop unless the test has been read and the results dictated
• Charges generated when documentation completed
• Batch entry – manual keying of charges
• Explode/linked charges generate multiple charges that are routinely performed
Charge Capture Processes
81
Charge Panels, Explodes or Links
82
• There are two distinct ways to assess the effectiveness of
charge capture processes, both of which are necessary
for ensuring optimal results
• Chart auditing which identifies lost charges but rarely
remediates root causes
• Technology which can identify potential missed charges more
efficiency and comprehensively than the traditional sample-
based chart auditing techniques
• Can help reduce charging errors over time
Manual versus Automated Processes
83
• When charge capture improvements occur, the
net revenue impact will be recognized
• Analyze payer mix, contracts, carve-outs, add-ons,
outliers, implants, high-dollar drugs, with some
consideration for productivity measures
Manual versus Automated Processes
84
85
Recommended ResourcesTools of the Trade
Medicare contractor bulletins and advisories
Medicare manuals:
◦ Claims Processing Manual (combination of the old hospital, intermediary, and carrier manuals)
◦ Benefit Policy Manual
◦ Provider Reimbursement Manual
◦ National Coverage Determinations Manual
Transmittals
Office of Inspector General
Audits and Work Plan
NCCI edits (National Correct
Coding Initiative edits)
Coverage determinations
Addendum B
Internet Resources
86
Medicare’s Main Website http://www.cms.hhs.gov
87
• Uniform Billing Editor, Optum360
• CPT ® 2017―AMA
• HCPCS 2017―Medicare-specific codes
• Coders’ Desk Reference, Optum360
• CPT ® Changes: An Insider’s View―AMA
• Hospital Chargemaster Guide, Various Publishers
• CPT Assistant―AMA
• Software Products
Additional Resources
88
Decisions:
◦ Make chargemaster Medicare compliant?
Yes―Elimination of nonreportable procedures
and charge lines. May leave money on the table
No―Bill other payers
Facility must ensure nonreportable charges are
NEVER submitted to Medicare as covered services:◦ Computer edits typically only fail-safe methodology
Structure of the Chargemaster
89
7%26%
13%
9%
45%
Self Pay and
Others
Managed Care
Blue
Cross/Commercial
Medicaid
Medicare
Median Payer Mix
90
SER VIC E
C OD E D ESC R IP T ION R EVISED D ESC R IP T ION P R IC E R .C .
R EV
R .C . H C P C S
R EV
H C P C S M C A ID
R EV
M C A ID
731846 B A LLOON D IA LA T ION C A T H ET ER S 630.25 621 272 C 1726 Y7107
731847 B ILIA R Y ST ON E R EM OVA L B Y T T UB E 1,354.00 320 74327 74327
731848 B IR D S N EST F ILT ER 1,320.00 621 278 C 1880 Y7107
731849 B ON E B X SUP ER F IC IA L 176.00 361
731850 B X LUN G/ M ED IA ST IN UM 176.00 361
731851 EXC H A N GE GUID EWIR E 88.25 621 272 C 1769 Y7107
731852 F EM OR A L R UN OF F (UN I) 986.00 320 75710 75710
731853 F EM OR A L R UN OF F A R T ER IO (B I) 1,427.00 320 75710 75716 75710 75716
731854 M R A A B D OM EN M R A A B D OM EN WO C ON T 1,100.00 610 74185 C 8901 74185
731855 M R A C H EST M R A C H EST WO C ON T 1,100.00 610 71555 C 8910 71555
731856 M R I C H EST M R I C H EST WO C ON T 1,068.00 610 71555 C 8910 71555
731857 M R A A B D OM EN W&W/ O C ON T 1,363.00 610 74185 C 8902 74185
731858 M R A A B D OM EN W/ C ON T 1,213.00 610 74185 C 8900 74185
Chargemaster Accommodating Additional Payer Requirements
91
• Mastering change is key element for success
• 2017 offers new challenges
• Good luck!!!
Final Thoughts
92
Glenda J. Schuler, RHIT, CPC, COC
• Vice President, Revenue Cycle Solutions, for HCS HealthCare Consulting
Solutions
• AHIMA-Approved ICD-10-CM/PCS Trainer
• Over 39 years experience in billing, coding, chargemaster, CPT, revenue
cycle, compliance
• National speaker for AAPC, AHIMA, state hospital associations, state
HIMA chapters, VHA/Vizient, HFMA and other organizations specific for:
• Ambulatory Payment Classifications
• Chargemasters
• OCE Editor and CCI reporting
• Modifiers
• gschuler@hcsglobal.net
Biography:
93
•Since 1996 HealthCare Consulting Solutions (HCS) has provided a broad spectrum of services and solutions in revenue cycle management, chargemaster maintenance, coding, documentation, reimbursement/billing, compliance and education/training for hospitals and physician practices, including:
• Inpatient (MS-DRGs), Outpatient (APCs) and Physician Practice Due Diligence & Compliance Risk Assessments including RAC, CERT, ZPIC, MAC/Carrier & OIG target areas
• CAH and Rural Health Clinic Compliance Audits and Education/Training
• DMEPOS Reviews, Operational Assessments and Education/Training
• IRF, IPF, SNF, HHA and Hospice Reviews
• Physician Documentation Assessments and Education/Training
• Revenue Cycle and Business Operations Assessments (Physician and Facility)
• Comprehensive Chargemaster Analysis, Supply and Pharmacy Assessments
• Strategic Pricing and Clinical Profile Assessments
• Client-Specific Educational Workshops and Conferences
• ICD-10-CM/PCS Education – Providers and Coders
HealthCare Consulting Solutions
94
For additional information on our consulting and education/training solutions, please contact:
Jeff Neustaedter, President
HCS HealthCare Consulting Solutions
800.659.6035
816.309.8600 Cell
jneustaedter@hcsglobal.net
www.hcsglobal.net
For Additional Information:HealthCare Consulting Solutions
95
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