This document provides information on managing a hospital's charge description master (CDM), which is the hospital's pricing catalog for billing procedures, services, and supplies. It discusses the definition and uses of the CDM, maintenance and review processes, integration with other systems, performing charge capture reviews, and regulatory expectations. The speaker is from Navigant Consulting and provides consulting services to help hospitals improve revenue cycle performance and billing compliance.
Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.
Sun Knowledge Revenue Cycle Management ServicesSun Knowledge
Sun Knowledge Revenue Cycle Management gives you a clear visibility of your finances through payment follow-up. Prosthetics and orthotics billing are handled diligently.
Vee Technologies provides a host of hybrid and versatile solutions for credentialing services. Our team expertly handles payer enrollment and contracting for our clients, turning an arduous task into a quick and easy process.
https://www.veetechnologies.com/industries/healthcare-payer/provider-network-data-management/credentialing.htm
Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.
Sun Knowledge Revenue Cycle Management ServicesSun Knowledge
Sun Knowledge Revenue Cycle Management gives you a clear visibility of your finances through payment follow-up. Prosthetics and orthotics billing are handled diligently.
Vee Technologies provides a host of hybrid and versatile solutions for credentialing services. Our team expertly handles payer enrollment and contracting for our clients, turning an arduous task into a quick and easy process.
https://www.veetechnologies.com/industries/healthcare-payer/provider-network-data-management/credentialing.htm
What is revenue cycle management? How does it impact your practice’s ability to maintain profitability? What are the critical steps to take when managing your revenue cycle? This Quirk Healthcare Solutions Insights webinar will lead you through the important healthcare provider business practice of revenue cycle management. We’ll discuss the stages of RCM, development of a fee schedule, establishing financial policies, billing and collection cycles, and the practical application of revenue cycle management.
Medical billing outsourcing assists health care entities through it’s revenue cycle management services, thus making the process smoother than ever. Medical billing outsourcing generally from USA improves revenue collection and ensures a smooth and consistent cash flow.
Trans-quest is a Healthcare Solutions provider..with a key focus on Revenue Cycle Management services for Physician Groups with a special emphasis on AR & Denial Management. Besides, Trans-quest has medical transcription capabilities and have been servicing various Group Physicians ranging from Multi Specialty, Cardiology, Endocrinology, Neurology, Ophthalmology, Oncology etc.
Transport Management Systems: How can they save you money?CLXLogistics
Find out what a Transport Management System can do for you and how you can achieve:
- Rapid deployment and a quick return on investment
- Significant transportation spend savings (our customers are consistently experiencing savings of 5% to 15+% off their annual transportation spend)
- Enhanced visibility of shipments, giving more control of orders and inventory.
- Significant reduction in manual effort through automatically planning/execution/settlement of shipments
- Comprehensive analytics to determine what is working well, and where improvement is required.
Medical necessity (CO 50) will be important denial if your DX is not matching with LCD policy. Know the basic of this denial to improve your medical billing
Risk adjustment documentation and coding overviewScott Quick
A collection of information from publicly available sources to help you:
• Know what Risk Adjustment (RA) is and why it is important to Medicare Advantage providers
• Understand Hierarchical Condition Categories (HCCs)
• Become familiar with Risk Adjustment Documentation and Coding Requirements
Basic Steps to Start Process
1. Infrastructure………………………………………….
2. Medical Billing Software……………………………..
3. EDI Enrollment……………………………………….
4. Requirement from Provider End……………………...
5. Data Migration Procedure…………………………….
6. India-US roles………………………………………….
7. India Operation Set up Flow Chart…………………….
8. Data Transmission/ Work Execution Flow Chart……
Dan Wellisch gave this presentation to the Chicago Technology For Vaue Based Healthcare Meetup at https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
A comprehensive view of how Medical Billing works. How to prepare medical claims, patient eligibility, example insurance cards, Medicare / Medicade, authorization of services, charge entry, fee schedules, claim submissions, posting ERAs / EOBs, rejected or denied claims (and their correction), secondary claims, cycle of a claim, revenue cycle, provider info needed on a claim, evaluation and management: coding and evaluations and basic components, etc,. By Medwave Medical Billing & Credentialing at http://medwave.io.
The Happy Marriage of Hospital Finance and Frontline OperationsHealth Catalyst
The hospital finance department typically acts as administrator and controller over hospital operations, at least in the eyes of frontline clinicians. Additionally, finance is burdened with the day-today tasks of balancing the books. And all too often, finance thinks they know what their customers want, but customers think that finance is isolated, secretive, and bureaucratic. The hospital finance department needs a makeover. To transition into the role of valued business partner and financial expert, finance needs to reinvent itself by:
Simplifying the flow of, and expand access to, information
Repositioning financial analysts as experts
Understanding what customers value
Learn how these straightforward business practices can support operations in their outcomes improvement efforts, and ultimately benefit the entire healthcare organization.
What is revenue cycle management? How does it impact your practice’s ability to maintain profitability? What are the critical steps to take when managing your revenue cycle? This Quirk Healthcare Solutions Insights webinar will lead you through the important healthcare provider business practice of revenue cycle management. We’ll discuss the stages of RCM, development of a fee schedule, establishing financial policies, billing and collection cycles, and the practical application of revenue cycle management.
Medical billing outsourcing assists health care entities through it’s revenue cycle management services, thus making the process smoother than ever. Medical billing outsourcing generally from USA improves revenue collection and ensures a smooth and consistent cash flow.
Trans-quest is a Healthcare Solutions provider..with a key focus on Revenue Cycle Management services for Physician Groups with a special emphasis on AR & Denial Management. Besides, Trans-quest has medical transcription capabilities and have been servicing various Group Physicians ranging from Multi Specialty, Cardiology, Endocrinology, Neurology, Ophthalmology, Oncology etc.
Transport Management Systems: How can they save you money?CLXLogistics
Find out what a Transport Management System can do for you and how you can achieve:
- Rapid deployment and a quick return on investment
- Significant transportation spend savings (our customers are consistently experiencing savings of 5% to 15+% off their annual transportation spend)
- Enhanced visibility of shipments, giving more control of orders and inventory.
- Significant reduction in manual effort through automatically planning/execution/settlement of shipments
- Comprehensive analytics to determine what is working well, and where improvement is required.
Medical necessity (CO 50) will be important denial if your DX is not matching with LCD policy. Know the basic of this denial to improve your medical billing
Risk adjustment documentation and coding overviewScott Quick
A collection of information from publicly available sources to help you:
• Know what Risk Adjustment (RA) is and why it is important to Medicare Advantage providers
• Understand Hierarchical Condition Categories (HCCs)
• Become familiar with Risk Adjustment Documentation and Coding Requirements
Basic Steps to Start Process
1. Infrastructure………………………………………….
2. Medical Billing Software……………………………..
3. EDI Enrollment……………………………………….
4. Requirement from Provider End……………………...
5. Data Migration Procedure…………………………….
6. India-US roles………………………………………….
7. India Operation Set up Flow Chart…………………….
8. Data Transmission/ Work Execution Flow Chart……
Dan Wellisch gave this presentation to the Chicago Technology For Vaue Based Healthcare Meetup at https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
A comprehensive view of how Medical Billing works. How to prepare medical claims, patient eligibility, example insurance cards, Medicare / Medicade, authorization of services, charge entry, fee schedules, claim submissions, posting ERAs / EOBs, rejected or denied claims (and their correction), secondary claims, cycle of a claim, revenue cycle, provider info needed on a claim, evaluation and management: coding and evaluations and basic components, etc,. By Medwave Medical Billing & Credentialing at http://medwave.io.
The Happy Marriage of Hospital Finance and Frontline OperationsHealth Catalyst
The hospital finance department typically acts as administrator and controller over hospital operations, at least in the eyes of frontline clinicians. Additionally, finance is burdened with the day-today tasks of balancing the books. And all too often, finance thinks they know what their customers want, but customers think that finance is isolated, secretive, and bureaucratic. The hospital finance department needs a makeover. To transition into the role of valued business partner and financial expert, finance needs to reinvent itself by:
Simplifying the flow of, and expand access to, information
Repositioning financial analysts as experts
Understanding what customers value
Learn how these straightforward business practices can support operations in their outcomes improvement efforts, and ultimately benefit the entire healthcare organization.
5 Steps to Ensure Compliance with Policies and ProceduresConvergePoint
Establishing effective policies and procedures does not begin and end with regulations. It takes the right amount of collaboration, the right types of distributive mediums, and the right methods to measure understanding. All of these things take an enormous amount of time and energy, but automating them with a software solution can increase efficiency, and ensure compliance with your policies and procedures. ConvergePoint explains the 5 steps to ensure compliance, and what software features to look for to choose the best possible solution. View our Policies and Procedures solution features at http://www.convergepoint.com/policy-management-software
The benefits of revenue cycle and compliance collaborationBESLER
This presentation highlights the importance of the working relationship between hospital Revenue Cycle and Compliance teams. This complimentary partnership can become seamless by utilizing the data analytics obtained from 835 and 837 data sets, Return to Provider (RTP), CERTs, Readmissions, ZPICs, HACs, RACs and Transfer DRGs. The combination of this data can assist in quickly identifying and resolving issues prior to provider submission, reducing days in AR and improving cash in the door.
How can you be successful at healthcare revenue cycle management.pdfCosentus
The best way to be successful at healthcare revenue cycle process is to outsource RCM services. Cosentus is one of the best companies that can help you get the desired result in your healthcare RCM. Visit their website today and get the best RCM service!
Driving Value - Taking the Healthcare Revenue Cycle to the Next Level.pdfAGSHealth1
As hospitals and healthcare systems evolve to meet the needs of a growing and aging population, they find themselves struggling to remain financially healthy.
https://www.agshealth.com/blog/driving-value-taking-the-healthcare-revenue-cycle-to-the-next-level/
In the world of healthcare, there are many aspects that come together and make healthcare organizations work. While the main focus is on providing quality healthcare services, other aspects, like employee satisfaction, equipment quality, healthcare revenue cycle management, and much more are also equally important to get the services going smoothly and ensure that the healthcare provider receives the payment for their services on time.
Revenue Cycle Management in healthcare encompasses the entire administrative process involved in getting paid for the services you provide to your patients. The process begins when a patient first calls to schedule an appointment and ends when all fees have been collected and verified.
Medical billing is becoming increasingly more complex. It is only going to get more difficult as new codes are added and more detailed patient information is required to be submitted with the claim. Add to that, physicians and other service providers are required by various insurers to provide details not previously necessary.
One small error can result in the claim not being paid promptly, completely or possibly even being denied.
Unlocking Efficiency and Boosting Profits_ The Benefits of Outsourcing Revenu...Doctors Back Office
Running a successful healthcare organization requires seamless management of the revenue cycle. From patient registration and billing to claims submission and payment processing, the revenue cycle is a complex and time-consuming process. In today's competitive landscape, healthcare providers are turning to outsourcing revenue cycle management (RCM) to unlock efficiencies and boost profits.
Outsourcing RCM offers numerous benefits. Firstly, it allows healthcare organizations to focus on their core competencies and patient care, while leaving the intricate details of billing and payment processing to experts. This not only improves operational efficiency but also enhances patient satisfaction.
How 24-7 Medical Billing Services Enhanced Financial Performance By Transform...CharlieRobinson32
There are various revenue cycle management tasks that must be done, and each is critical to a center’s financial health. Even minor errors with one or more of an ASC’s revenue cycle processes can have serious short- and long-term consequences. Such consequences can range from payment delays and denials to lost payments and compliance challenges. Discover how 24/7 medical billing services improved financial performance by revolutionizing ASC billing.
The story of the Ohio-based ASC was on a similar track with the suffering of thousands of dollars while operating an ambulatory surgical center (ASC) and billing. Keeping in mind the urge to deal with the consequences, the client approached and outsourced ASC billing services of 24/7 Medical Billing Services.
Overcoming the Struggles of Small PracticesBen Quirk
Small practices face many struggles on the road to success. This webinar overviews the top obstacles they face, addresses the reasons behind the decline in numbers of independent practices, and provides solutions for them to remain successful despite the challenges.
2. Page 2
Managing Your Charge
Description Master
MdHIMA Annual Meeting
Baltimore Convention Center; Baltimore, Maryland
June 5, 2008
HP3
A part of Navigant Consulting
3. Page 3
Table of Contents
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
5. Page 5
Charge Description Master 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 Description Master 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 Description Master 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 of the Charge Description Master
Accurate CDM and
Charge Capture Practices
Clean Claims
Data IntegrityBilling Compliance
10. Page 10
Charge Description Master 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 CDM Revisions
» 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)
15. Page 15
OIG Expectations for 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 Life Consequences . . .
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.
18. Page 18
Charge Description Master 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
20. Page 20
Performing a Charge 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
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 Unique Approach
» 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
It is essential to clean billing.
It can be a cause of non-compliant claims.
It is essential to clean billing.
It can be a cause of non-compliant claims.
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)
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)
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)
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)
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)
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)
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)