Chargemaster and Beyond?

Follow-Up Tips, Tricks and Strategies TRAINING FOR REVENUE CYCLE STAFF TO BE SUCCESSFUL.

Kittitas Valley Healthcare Becky Littke – Revenue Cycle Director

Services Acute Care

Swing Beds

Urgent Care Center

Primary Care Clinics

Specialty Clinics

Outpatient Imaging & Therapies

2018 KVH Statistics Annual Admissions – 944

Annual Births – 332

Observation Days – 1124

Annual Emergency Visits – 13,751

Annual Office Visits – 58,500

Goals & Objectives

What is a Chargemaster?

Why is the Chargemaster important for Revenue Cycle staff?

Learn differences between reimbursement models

Similarities & differences between Commercial & Government

payers (Medicare/Medicaid)

How does contract language impact reimbursement?

Identify additional impacts on reimbursement

Tools – Where can I learn more? Helpful Websites

Why is this important?

Remittance reasons

Why is it important?

MUE & CCI edit examples

What is a

Chargemaster?

A Chargemaster is a set of charges used in

hospital billing

Supplies

Pharmacy

Procedures

The Chargemaster setup determines how

charges appear on a claim and patient

statements

Other common names include CDM or

Charge Description Master

Differences – Hospital vs. Health System

Charges – Key Components

Charge Number

Description

Revenue Code

CPT/HCPCS Code

Rate or Price

When to expect updates…

Annually

AMA CPT Codes

CMS HCPCS Codes

Medicare Rules:

OPPS, IPPS, MPFS, CAH

Pricing (facility dependent)

Quarterly

CMS HCPCS Code

Medicaid Regulations

Daily/Weekly

CMS Transmittals

Chargemaster Updates

Service line changes

What changes?

CDM is fluid and ever evolving

CPT & HCPCS Codes

Billing Regulations

Payor Rules

Revenue Budgets

Reimbursement

Contractual agreements

Why do the CDM Updates Matter to you?

Compliance

Proper Education & monitoring deters fraud

Denials

Finance

Accurate Revenue

Cash Flow

Changes in Reimbursement

Billing

Effective Follow-up strategies

Who are the Stakeholders when the CDM

Changes?

Department Managers

Information Systems Staff

Registration

Referral/Authorization

Coordinators

Coding

Finance

Payors

Revenue Integrity Staff

Clinicians/Physicians

When and Where are the updates made?

New CPT/HCPCS codes – Effective January 1st, and updated quarterly

Payors do not always have their systems updated at this time

Changes you will see in your EMR:

Charge Records

Orders

Charge systems

Radiology

Operating Room

Therapists Flow sheets

Charge Capture tools

HCPCS/CPT & Revenue Codes

Healthcare Common Procedure Code System (HCPCS) or Current Procedural Terminology (CPT)

Code sets defined by Medicare and the AMA

There are codes for procedures, some supplies and pharmaceuticals

Revenue Codes (we will see examples on the next slide)

General rule is to assign a revenue code that best describes the service location

Payers may have preferences on HCPCS/CPT & Revenue Combinations

Revenue Codes Therapy Services

CPT/HCPCS & Revenue Code Crosswalk

Status Indicators & Bundling

Status indicator is Assigned by CMS Annually

Important for understanding reimbursement for payers that follow CMS reimbursement methodology

SI=N – Packaged in APC Rate

SI=B – Codes not recognized by OPPS

SI=C – Inpatient only procedure

SI=Q – Packaged if certain criteria are met

SI=S – Not discounted when multiples

SI=T – Discounted when multiples

CCI, Payer Applied Edits & Audits

CCI & Payer Applied Edits

Identifies Codes that cannot be billed together

Codes that need a modifier when billed together

Medical Necessity – CPT/Diagnosis combinations

Annual CPT Updates – timing

Forensic Audits

Refer to definition of what is included in room rate

Focus on supplies & pharmaceuticals not deemed separately reportable

Modifiers

Common Modifiers – Please see CPT book for in depth definitions

25 – Significant E&M on same day as a procedure

59 – Distinct Procedural Service

91 – Repeat Clinical Diagnostic Lab Test

50 – Bilateral Procedure (use when CPT code is not inherently bilateral)

Appropriate use of Modifiers

When services can clearly be confirmed as distinct

Separate Time and/or location

Practical Examples

ED Visit with a Procedure – Use of Modifier 25

E&M 99281-99285

Procedure has a status indicator or “S” or “T”

Must be separately identifiable and performed by same provider.

Reimbursement Models

Inpatient

Outpatient

Critical Access

Indian Health

Rural Health

Skilled Nursing Facilities

Home Health

Hospice

Inpatient Reimbursement Methods

Medicare Severity –Diagnosis Related Group (MS-DRG)

All Patient – Diagnosis Related Group(AP-DRG)

All Patient Refined - Diagnosis Related Group (APR-DRG)

Percentage of Charge

Per Diem

Case Mix Group

Cost-based reimbursement

Medicare Severity Long-Term Care Diagnosis Related Groups (MS-LTC-DRGs)

Inpatient

Outpatient Reimbursement Methods

Outpatient_

Ambulatory Payment Classification (APC’s)

Enhanced Ambulatory Payment Group (EAPG)

Resource Based Relative Value System (RBRVS)

Percentage of Charge

Cost-based reimbursement

Inpatient Reimbursement models

Payment Method Care Environment

Key Driver

MS-DRG/AP-DRG/APR-DRG

Acute Inpatient

Diagnosis/Reason for visit

CMG

Inpatient Rehab

Impairment level is assigned

impairment group code

MS-LTC-DRG

Long-Term Care Hospital

Long-Term Case Mix Group

Per Diem

Skilled Nursing or Acute

Daily paid Rate

Cost-Based Reimbursement

Critical Access Hospitals

RCC’s & Cost Report

Outpatient Reimbursement Models

Payment Method Care Environment Key Driver

APC’s

Outpatient/Ambulatory Surgery

Center

CPT’s assigned a group, group

assigned a weight

RBRVS

Physician Clinic

CPT assigned weight

Application Question For each care setting, match reimbursement model:

1. Skilled Nursing Facility

2. Inpatient Acute Care

3. Outpatient Imaging Center

4. Primary Care Provider

5. Inpatient Rehab

A. Per Diem

B. MS-DRG/AP-DRG/APR-DRG

C. APC/RBRVS

D. RBRVS/APC

E. CMG

Similarities & Differences between

Commercial and Government Payers

Similarities

May use same payment methodologies as Medicare

Apply CCI Edits to claims

Medical Necessity checks

Differences

Coverage Determinations vs. Referrals & Authorizations

Contract defines payment terms vs. regulations

Commercial Payors reimburse at higher rates

Why is a Contract Important?

Contract between Payer & Healthcare Provider

Defines expectations of healthcare provider and payer.

Describes reimbursement methodology (we will learn about several options

in the next few slides).

Most contracts have Chargemaster rate increase provisions

Defines coverage of services

Contract between Payer and Beneficiary (benefit policy manual)

Outlines covered & non-covered services

Defines copays, coinsurance and deductibles

Contract Language & Reimbursement impact

Contract language may carve out services they will not pay for.

Example: Outpatient Visit codes in a hospital outpatient department

Notification requirements (authorization, referral, census)

Payer Policies

Contract changes with no dual signature requirements

Contractual Language may determine which CPT & revenue codes are not

reimbursed separately.

Examples – Supplies (270-279), Recovery (710)

What do you say if…

You call the customer service team of Premera, a DRG payer, and they

indicate to you that they are denying the last three days of a 8 day

inpatient stay?

You have a outpatient claim that contractually should be reimbursed

using APC methodology and the customer service representative is

indicating the entire claim denied because of a charge reported under

revenue code 272.

You have an outpatient claim for an APC payer that has two procedures,

both that have a status indicator S, and the payer is telling you they will

only reimburse one of them?

Practical Examples

EKG’s – Work flow matters…

93000 - Routine EKG using at least 12 leads including interpretation

and report

93005 - Routine electrocardiogram (EKG) with tracing using at least

12 leads

93010 - Routine electrocardiogram (EKG) using at least 12 leads with

interpretation and report

Practical Examples

Bundled vs. Unbundled – CT Abdomen & Pelvis

72194 - Computed tomography, pelvis; without contrast material, followed by contrast

material(s) and further sections

74170 - Computed tomography, abdomen; without contrast material, followed by

contrast material(s) and further sections

74178 - Computed tomography, abdomen and pelvis; without contrast material in one

or both body regions, followed by contrast material(s) and further sections in one or

both body regions

***** Please note when contrast is used, you will have a contrast charge as well. This

should hit a CCI edit or possibly a denial.

Computed0Computed0

Practical Examples Chest X-Ray Coverage Determination

Tools & Helpful Websites

Uniform Billing Editor

AMA CPT Book

HCPCS Level II

cms.hhs.gov

Noridianmedicare.gov

Washington Medicaid Website

Payer websites

Web-based products

”

“

Questions?

YOU HAVE EVERY REASON AND EVERY ABILITY TO MAKE EACH DAY MORE FULFILLING AND LIFE-AFFIRMING THAN THE LAST. EXPECT THE BEST OF

YOURSELF, AND DELIVER IT.

— RALPH MARSTON

Thank you for your participation!

blittke@kvhealthcare.org