Chargemaster Basics and Beyond

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

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

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.

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

*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

Chargemaster Basics UB Charge Number Description Price Billing Description Revenue Code CPT/HCPCS Revenue Center 7111037 H XR CHEST MIN 4 VIEWS? XR CHEST MIN 4 VIEWS 0324 71030 7111038 H XR CHEST PA & LAT? XR CHEST PA & LAT 0324 71020 3131103 H CHEMO IV INFUSION 1ST HOUR INITIAL? Chemo Inf 1st hour 0335 96413 3131104 H CHEMO IV INFUSION ADDITIONAL HOURS? Chemo Inf Addl hours 0335 96415 3131105 H CHEMO IV INFUSION ADDL DRUG/SEQ 1ST HOUR? Chemo Inf addl med/hr 0335 96417 3170000 H OR IMPLANT MISC MANUAL manual Miscellaneous Implant 0278 3170001 H OR SUPPLY MISC MANUAL manual Miscellaneous Supply 0270 3110010 H OR LEVEL 1 FIRST 30 MINUTES? OR LEVEL 1 FIRST 30 MINUTES 0360 3110011 H OR LEVEL 1 ADD'L 15 MINUTES? OR LEVEL 1 ADD'L 15 MINUTES 0360 3110020 H OR LEVEL 2 FIRST 30 MINUTES? OR LEVEL 2 FIRST 30 MINUTES 0360 3110021 H OR LEVEL 2 ADD'L 15 MINUTES? OR LEVEL 2 ADD'L 15 MINUTES 0360 3172220 H OR PACEMAKER,ENPULSE SR? Pacemaker 0278 C1786 6111250 H RXC MED WITH 250 REV CODE #N/A H RXC MED WITH 250 REV CODE 0250 101801 6111259 H RXC MED WITH 259 REV CODE #N/A H RXC MED WITH 259 REV CODE 0259 101801 4110000 H ED SCREENING? Emergency Visit 0450 99281 103300 4110001 H ED LOW LEVEL VIST? Emergency Visit 0450 99282 103300 4110002 H ED LOW LEVEL VISIT W PROCEDURE? Emergency Visit 0450 9928225 103300 1111100 H NICU INTENSIVE? Room Intensive 0174 1111101 H PICU INTENSIVE? Room Intensive 0203 5170056 H CS CATH DYL PERM 12.5FRX28CM? Dialysis Catheter 0278 C1750 101803 5170057 H CS CATH DYL PERM 8FRX24CM? Dialysis s Catheter 0278 C1750 101803 5170058 H CS CATH DYL PERM CURV 12.5FRX38CM? Dialysis Catheter 0278 C1750 101803

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

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

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

Coded in System HCPCS Code/Description Rev Code 24640/TREAT ELBOW DISLOCAT 450 Reimbursement Medicare 99282 $88 24640 $112 CPT Code 99282 is hard coded in the CDM

Missing Charge Sample Charge Section of UB04 42 Rev Code 43 Description 44 HCPCS/RATES 45 DATE 46 UNITS 47 TOTAL CHARGES 250 Pharmacy 05/01/06 2 15.00 450 Emergency 99282 05/01/06 1 215.00 450 Emergency 24640 0.00 001 Total Charges 230.00 Missing modifier 25 also!

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 05/01/06 2 15.00 456 Emergency 9928225 05/01/06 1 215.00 001 Total Charges 230.00 *CPT code 24640 did not cross as code was looking for a 450 revenue code.

Example of table integration HCPCS Code/Description Rev 24640/TREAT ELBOW DISLOCAT 360 42820/REMOVAL TONSILS(ADEN) 69424/REMOVAL EARTUBE 360 Reimbursement Medicare 24640 $112 42820 $1683 69424 $1159

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 05/01/06 2 15.00 360 Surgery 24640 05/01/06 6 5000.00 360 Surgery 67424 0.00 001 Total Charges 5015.0000 *Missing CPT code, $ does not spread out and can cause code loss; watch surgery units on timed charges.

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)

RAC Demonstration Project Percentage of Overpayments by Outpatient Hospitals Cumulative to 3/27/2008 79% Excessive/Multiple Units All Other Reasons 21% Source: The Medicare RAC Demonstration http://www.cms.gov/rac/downloads/racevaluationreport.pdf Appendix F: Top Errors by Provider Type <Accessed May 16, 2010>

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 $1,100,000 1084 Oxaliplatin (J9263) Incorrectly Coded $614,269 346.5mg $9.38 Darbopoetin (J0881) Incorrectly Coded $260,176 726 1 mcg $2.91 Totals $1,974,445 2156 State: NY Source: The Medicare RAC Demonstration http://www.cms.gov/rac/downloads/racevaluationreport.pdf Appendix H: Top Services With Underpayments <Accessed May 16, 2010>

Pharmaceutical Complexities The order is not ordered in billing units J9263 Oxaliplatin billing unit = 0.5mg Reimbursement is $9.55 55perbilling 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

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

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

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

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

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.

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

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

Questions? Children s Memorial Hospital 2300 Children s Plaza Box #26 Chicago, IL 60614 (312) 573 4113 mniedzwi@childrensmemorial.org