Chargemaster Basics and Beyond

Transcription

1 Chargemaster Basics and Beyond Marilyn Hart Niedzwiecki CPA, MBA, RN, CPC, CPC H Director Revenue Integrity Children's Memorial Hospital, Chicago, IL

2 Children s Memorial Hospital Chicago 247 Bed Children s Hospital Only free standing pediatric hospital in Illinois $1 billion hospital gross revenue Building new hospital Opens Summer 2012

3 Objectives Increase awareness of the complexities of CDM management and the interrelationships it has in the revenue eeuecycle. Develop an understanding of concerns and problem areas with the CDM. Develop an understanding di of why a clean CDM does not ensure a clean bill. Provide the revenue cycle auditor with information that will be valuable in developing audit plans.

4 Chargemaster the hub of revenue cycle management PFS Physician Billing Clinicians Finance Managed Care Chargemaster Customers Compliance IM HIM

5 *A clean chargemaster does not equate to revenue integrity Constantly changing or revised interpretation of rules Not intuitive to clinicians Requires knowledge related to hospital operations Who charges for what services; sometimes an overlap Knowledge of systems is essential Interfaces Patient accounting

6 Chargemaster Basics UB Charge Number Description Price Billing Description Revenue Code CPT/HCPCS Revenue Center H XR CHEST MIN 4 VIEWS? XR CHEST MIN 4 VIEWS H XR CHEST PA & LAT? XR CHEST PA & LAT H CHEMO IV INFUSION 1ST HOUR INITIAL? Chemo Inf 1st hour H CHEMO IV INFUSION ADDITIONAL HOURS? Chemo Inf Addl hours H CHEMO IV INFUSION ADDL DRUG/SEQ 1ST HOUR? Chemo Inf addl med/hr H OR IMPLANT MISC MANUAL manual Miscellaneous Implant H OR SUPPLY MISC MANUAL manual Miscellaneous Supply H OR LEVEL 1 FIRST 30 MINUTES? OR LEVEL 1 FIRST 30 MINUTES H OR LEVEL 1 ADD'L 15 MINUTES? OR LEVEL 1 ADD'L 15 MINUTES H OR LEVEL 2 FIRST 30 MINUTES? OR LEVEL 2 FIRST 30 MINUTES H OR LEVEL 2 ADD'L 15 MINUTES? OR LEVEL 2 ADD'L 15 MINUTES H OR PACEMAKER,ENPULSE SR? Pacemaker 0278 C H RXC MED WITH 250 REV CODE #N/A H RXC MED WITH 250 REV CODE H RXC MED WITH 259 REV CODE #N/A H RXC MED WITH 259 REV CODE H ED SCREENING? Emergency Visit H ED LOW LEVEL VIST? Emergency Visit H ED LOW LEVEL VISIT W PROCEDURE? Emergency Visit H NICU INTENSIVE? Room Intensive H PICU INTENSIVE? Room Intensive H CS CATH DYL PERM 12.5FRX28CM? Dialysis Catheter 0278 C H CS CATH DYL PERM 8FRX24CM? Dialysis s Catheter 0278 C H CS CATH DYL PERM CURV 12.5FRX38CM? Dialysis Catheter 0278 C

7 Terminology CPT Current Procedural Terminology published by the American Medical Association HCPCS Healthcare Common Procedure Coding System published by CMS Charge Number (or code) unique identifier in an organization s chargemaster (CDM) Revenue Center (cost center) area receiving the revenue for the charge

8 Terminology. UB Revenue Code 4 digit number that represents accommodations or services on a hospital claim form Numerous rules and regulations Affects reimbursement Examples 0174 Newborn Level liv 0173 Newborn Level III 0172 Newborn Level II

9 Understanding Coding in the CDM CPT codes SoftCoded assigned by Health Information Management Hard Coded assigned in the CDM Understanding how codes cross to the bill Varies with each organization Knowledge of patient accounting systems

10 Coded in System HCPCS Code/Description Rev Code 24640/TREAT ELBOW DISLOCAT 450 Reimbursement Medicare $ $112 CPT Code is hard coded in the CDM

11 Missing Charge Sample Charge Section of UB04 42 Rev Code 43 Description 44 HCPCS/RATES 45 DATE 46 UNITS 47 TOTAL CHARGES 250 Pharmacy 05/01/ Emergency /01/ Emergency Total Charges Missing modifier 25 also!

12 Example of edited revenue code in CDM Sample Charge Section of UB04 42 Rev Code 43 Description 44 HCPCS/RATES 45 DATE 46 UNITS 47 TOTAL CHARGES 250 Pharmacy 05/01/ Emergency /01/ Total Charges *CPT code did not cross as code was looking for a 450 revenue code.

13 Example of table integration HCPCS Code/Description Rev 24640/TREAT ELBOW DISLOCAT /REMOVAL TONSILS(ADEN) 69424/REMOVAL EARTUBE 360 Reimbursement Medicare $ $ $1159

14 The bill lost reimbursement Sample Charge Section of UB04 42 Rev Code 43 Description 44 HCPCS/RATES 45 DATE 46 UNITS 47 TOTAL CHARGES 250 Pharmacy 05/01/ Surgery /01/ Surgery Total Charges *Missing CPT code, $ does not spread out and can cause code loss; watch surgery units on timed charges.

15 Drug Billing Units Billing for Drugs, Biologicals, and Radiopharmaceuticals Hospitals are strongly encouraged to report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. It is also of great importance that hospitals billing for theseproductsmake certain thatthereportedthe unitsofservice service ofthe reported HCPCS codes are consistent with the quantity of a drug, biological, or radiopharmaceutical that was used in the care of the patient. April 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS)

16 RAC Demonstration Project Percentage of Overpayments by Outpatient Hospitals Cumulative to 3/27/ % Excessive/Multiple Units All Other Reasons 21% Source: The Medicare RAC Demonstration Appendix F: Top Errors by Provider Type <Accessed May 16, 2010>

17 Top Services Resulting in Underpayments for Outpatient Hospitals (cumulative to 3/27/08) Specifics Reason Amount trefunded d Number of fclaims Billing Unit Reimbursement Drug codes in general Incorrectly Coded $1,100, Oxaliplatin (J9263) Incorrectly Coded $614, mg $9.38 Darbopoetin (J0881) Incorrectly Coded $260, mcg $2.91 Totals $1,974, State: NY Source: The Medicare RAC Demonstration Appendix H: Top Services With Underpayments <Accessed May 16, 2010>

18 Pharmaceutical Complexities The order is not ordered in billing units J9263 Oxaliplatin billing unit = 0.5mg Reimbursement is $ perbilling unit Order reads Oxaliplatin 100 mg over 4 hours and the units need to be 200 Reimbursement if 100 units are reported on bill = $955 *Reimbursement if 200 units on bill = $1910 Reimbursement if 1 unit on the bill = $9.55

19 Billing Edits Changing an item required by a payer for billing: Where do they happen? Patient Accounting System Manually by a biller Programmed into the electronic system Why do they happen? Payer has unique requirements Solve an operational issue Interpretation of a problem

20 Examples of Edits Medicaid reimbursement regulations Reimbursement is not standard to CPT code definition Special billing rules on quantities Operational Complexities Surgerycharged in incremental units and need to report each line as a 1 Blood transfusion charging

21 What can go wrong? Incorrect programming Not updated Lack of documentation Incomplete understanding by others Poor communication Rules interpreted incorrectly Generalizations

22 Vl Valuable Skills Become knowledgeable about systems and interfaces used in the revenue cycle Familiarize audit staff with basic coding principles p Understand common public schedules Addendum B HCPCS Codes National Correct Coding Initiatives

23 The Revenue Cycle Audit Who approves the following? CDM Changes Edits Are they appropriate? Can they be done in the patient accounting system? Is there documentation? Charge policy, CDM guide, edits and processes in general.

24 Is there a multidisciplinary team to discuss complex issues? Revenue Integrity Committee PFS Discussions Should professional billing be considered? Approval processes?

25 The Audit continued Perform audits from chart through the electronic billing system Drug units (fromorder order to bill and electronic claim CPT/HCPCS Codes Not rolled up Crossing correctly when assigned by HIM Charges reported correctly Correct use of modifiers (include who enters them) Are edits working correctly

26 Questions? Children s Memorial Hospital 2300 Children s Plaza Box #26 Chicago, IL (312) mniedzwi@childrensmemorial.org