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Managing the Chargemaster
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- 2. Page 2 Managing YourCharge Description Master MdHIMA Annual Meeting Baltimore Convention Center; Baltimore, Maryland June 5, 2008 HP3 A part of Navigant Consulting
- 3. Page 3 Table ofContents Section 1 » Definitions and Uses Section 2 » Maintenance and Review Section 3 » Integration Section 4 » Charge Capture Review Section 5 » Questions? Section 6 » About Your Speaker & NCI
- 4. Page 4 Definition andUses Section 1
- 5. Page 5 Charge DescriptionMaster Definition » A hospital-specific file that includes billing rates for all procedures, services, supplies and drugs on hospital bills and claims. › Therapeutic Examinations and Procedures › Diagnostic Examinations and Procedures › Pharmaceuticals › Radiopharmaceuticals › Blood Products › Supplies › Implants » It is the hospital’s “price book” and “menu of services”. » Also referred to as the “CDM” or “chargemaster”.
- 6. Page 6 Charge DescriptionMaster Structure » Each line item can have several corresponding data elements. › Billing Description › Revenue Code › CPT/HCPCS Codes › Modifiers › Multiplier Units › RVUs (i.e. HSCRC) › Charge Amount » Each item in file is assigned a unique identification code. » Description of service, recognizable by billing staff. » Hospitals use their own unique methodologies to code, capture, calculate and update their charges. › Time-based vs. Procedure-based › Hard-coded vs. Not coded
- 7. Page 7 Charge DescriptionMaster Example Dual Chamber AICD System Implant Procedure Procedure-Based/Hard-Coded in CDM Time-Based/Not-Coded in CDM The above example is for demonstration purposes only. All codes, RVUs, multipliers may not be accurate for a hospital based on their specific needs.
- 8. Page 8 Importance ofthe Charge Description Master Accurate CDM and Charge Capture Practices Clean Claims Data IntegrityBilling Compliance
- 9. Page 9 Maintenance andReview Section 2
- 10. Page 10 Charge DescriptionMaster Maintenance » Hospital-Specific CDM Structure Rules › Use of statistical or no-charge items › Determination of allowable items › Use of duplicate CPTs › Use of charge explosions › Standardized charge description master » Policies and Procedures › Maintenance Roles, Responsibilities and Expectations ‒ CDM Coordinator ‒ CDM Committee › Requesting CDM Revisions ‒ Standard form ‒ Review and feedback › Frequency of reviews and updates
- 11. Page 11 Maintenance Roles,Responsibilities and Expectations » CDM Coordinator › Designee for hospital to coordinate activities involving the CDM. › Level within hospital may differ based on hospital size, needs, etc. › Gatekeeper for final revisions. › Knowledge of regulatory requirements and revenue cycle processes. › Ability to communicate timely and effectively. › Leader of CDM Committee.
- 12. Page 12 Maintenance Roles,Responsibilities and Expectations » CDM Committee ‒ Lead by CDM Coordinator. ‒ Other members can include representatives of clinical and support departments ◦ Required ▫ Reimbursement ▫ Patient Financial Services ◦ As-Needed ▫ Clinical Services ▫ Information Services ▫ Compliance ▫ Internal and External Auditors ‒ Meet on a regular basis. ◦ Bi-weekly ◦ At least quarterly ‒ May report up through a higher committee. ◦ Corporate Compliance ◦ Finance and Audit ‒ May discuss operational charge capture issues, potential new services and service lines, internal and external audit requests and results. ‒ May determine need for internal and external audits.
- 13. Page 13 Requesting CDMRevisions » Who? › Clinical Departments › Patient Financial Services › CDM Coordinator/Committee » What? › Type of Revision ‒ New Test, Procedure or Service ‒ Correction ‒ Regulatory Update › Data Elements » When? › There is NEVER a wrong time for a revision! » Where and How? › On-line request › Paper request › Standardized form(s)
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- 15. Page 15 OIG Expectationsfor Maintenance » Office of the Inspector General - The enforcement arm of CMS › Civil monetary penalties › Sanctions » Compliance Guidance for Hospitals › http://www.oig.hhs.gov/fraud/complianceguidance.html › 02/23/98 Compliance Program Guidance for Hospitals › 01/27/05 Supplemental Compliance Program Guidance for Hospitals Because the Healthcare Common Procedure Coding System (HCPCS) codes and APCs are updated regularly, hospitals should pay particular attention to the task of updating the CDM to ensure the assignment of correct codes to outpatient claims. This should include timely updates, proper use of modifiers, and correct associations between procedure codes and revenue codes.
- 16. Page 16 Real LifeConsequences . . . SCENARIO Hospital bills and is reimbursed for services performed outside of the hospital. The staff performing the services did not indicate the patient location or type of service to charge entry staff. Similar services are provided within the hospital therefore billing staff do not question claims. The services are billed as if they were performed within the hospital walls. The hospital is reimbursed at a higher rate and benefit than would have been if the services were billed appropriately. CAUSE De-centralized CDM maintenance processes. Lack of charge capture knowledge within clinical department. Lack of participation of CDM Committee in creation of new service line. CONSEQUENCES The hospital is fined over $1 million and is placed under a corporate integrity agreement with the OIG for 5 years. Required training and annual external review cost the hospital hundreds of thousands of dollars that are exempt from cost reporting. New positions are created and better controls in place as required under agreement.
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- 18. Page 18 Charge DescriptionMaster Integration » Charges are often not captured by the “billing system” alone. › Order entry and clinical subsystems can generate the charge. › The CDM revision process should include a check and balance of any changes that would also change the use of any systems. Example Order Entry Mapping Report » The CDM can also be used to define additional tasks › HIM workload › Basis for billing rules › Collect data for decision support › Calculate RVUs for HSCRC compliance
- 19. Page 19 Charge CaptureReview Section 4
- 20. Page 20 Performing aCharge Capture Review » The CDM can be coupled with a usage report to review for potential billing compliance issues and to identify potential lost revenue/RVUs. » Preliminary steps of a charge capture review › Review departments separately › Look for high volume items, tests and procedures › Look for items, test and procedures that compliment each other ‒ Examples ◦ Cardiology ▫ Echocardiogram ▫ Holter Monitor ◦ Interventional Cardiology/Radiology ▫ AICD and Pacer Implantation ▫ Radiology Guided Organ Biopsies ▫ Cardiac Catheterization Injections/Imaging ◦ Nuclear Imaging ▫ Nuclear Stress Tests ▫ Radiopharmaceutical Usage
- 21. Page 21 Performing aCharge Capture Review » Charge Capture Review Steps › Step 1. Identify the area for review › Step 2. Identify all stakeholders › Step 3. Initiate Review › Step 4. Interviews › Step 5. CDM Review › Step 6. Develop Charging Guide › Step 7. Exit Interview › Step 8. Staff In-Service › Step 9. Post Implementation Audit
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- 23. Page 23 About YourSpeaker & Navigant Consulting Section 6
- 24. Page 24 Speaker Caroline Rader,MBA, MSHCA, CHC » Associate Director, Coding/Documentation » Baltimore, Maryland » Experience › 10+ years of billing compliance, charge description master and revenue cycle experience ‒ Industry and Consulting ‒ Maryland HSCRC and APC » Contact Information: › Email: caroline.rader@navigantconsulting.com › Phone: 419-463-9867 › Fax: 866-861-0084
- 25. Page 25 NCI Healthcare ProviderPractice Group » Our comprehensive services to healthcare providers include: › Performance improvement › Strategic advisory › Revenue performance improvement › Financial advisory › Supply chain management › Interim management
- 26. Page 26 Our Values Responsive– we anticipate and respond quickly to client needs. We are experts in highly regulated environments, and our deep industry knowledge enables us to develop innovative and practical solutions to our clients’ business challenges. Resourceful – as an integrated company, we are able to leverage the diverse skills and industry expertise of our professionals to help clients overcome the challenges of uncertainty, risk, distress and significant change. We work seamlessly, drawing from an array of resources, to help clients transform ideas in actions. Trustworthy – clients count on us for effective solutions, accurate answers and honest responses. We approach every task in a straightforward manner, providing independent and objective advice in which clients can have confidence. Innovative – we have a history of helping clients identify and implement innovative solutions to complex and challenging business issues. Our entrepreneurial culture encourages all professionals to be innovative exploring new ideas and methods to help clients address their business challenges.
- 27. Page 27 Our UniqueApproach » Integration – We believe it is imperative to integrate a strategic and operational focus. Linkages to financial and clinical performance are critical. » Experience – Our consultants have on average 10+ years of operational and/or consulting experience. Our senior resources work on the project – not just lead the project. » Flexibility – We are a consulting group consisting of highly experienced consultants. We bring methodology but tailor efforts to meet the clients needs and success factors. » Size – We are not too big…not too small. With over 300 employees serving the healthcare industry, we can leverage our operational, clinical, financial, regulatory and technical capabilities depending on the client’s needs. We believe there are key differentiators that drive Navigant Consulting’s unique approach to assisting our clients.
Editor's Notes
- #8 It is essential to clean billing. It can be a cause of non-compliant claims.
- #9 It is essential to clean billing. It can be a cause of non-compliant claims.
- #11 Covered vs. Non-Covered vs. Non-Billable Statistical Line Items Portable, Stat, Call-back and On-Call Services Accountability for Maintenance Non-Centralized vs. Centralized Control Individual Clinical Department vs. Finance Department vs. Compliance Department Team/Committee(s)
- #12 Covered vs. Non-Covered vs. Non-Billable Statistical Line Items Portable, Stat, Call-back and On-Call Services Accountability for Maintenance Non-Centralized vs. Centralized Control Individual Clinical Department vs. Finance Department vs. Compliance Department Team/Committee(s)
- #13 Covered vs. Non-Covered vs. Non-Billable Statistical Line Items Portable, Stat, Call-back and On-Call Services Accountability for Maintenance Non-Centralized vs. Centralized Control Individual Clinical Department vs. Finance Department vs. Compliance Department Team/Committee(s)
- #14 Covered vs. Non-Covered vs. Non-Billable Statistical Line Items Portable, Stat, Call-back and On-Call Services Accountability for Maintenance Non-Centralized vs. Centralized Control Individual Clinical Department vs. Finance Department vs. Compliance Department Team/Committee(s)
- #15 Covered vs. Non-Covered vs. Non-Billable Statistical Line Items Portable, Stat, Call-back and On-Call Services Accountability for Maintenance Non-Centralized vs. Centralized Control Individual Clinical Department vs. Finance Department vs. Compliance Department Team/Committee(s)
- #16 Covered vs. Non-Covered vs. Non-Billable Statistical Line Items Portable, Stat, Call-back and On-Call Services Accountability for Maintenance Non-Centralized vs. Centralized Control Individual Clinical Department vs. Finance Department vs. Compliance Department Team/Committee(s)
- #17 Covered vs. Non-Covered vs. Non-Billable Statistical Line Items Portable, Stat, Call-back and On-Call Services Accountability for Maintenance Non-Centralized vs. Centralized Control Individual Clinical Department vs. Finance Department vs. Compliance Department Team/Committee(s)