DYNAMIC CHARGEMASTER STRATEGIES AND EMERGING...

DYNAMIC CHARGEMASTER

STRATEGIES AND

EMERGING TRENDS

Glenda J Schuler, RHIT, CPC, COC

Vice President, Revenue Cycle Solutions

The information in this presentation is an overview and does not

contain all information necessary or available, and although we have

tried to include accurate and comprehensive information in this

educational presentation, please remember it is not intended as legal,

tax, business, financial or other professional advice.

Furthermore, this educational presentation is not inclusive of all of the

updates, changes, rules and citations impacting your hospital, health

system, clinic and/or department.

The information contained in this presentation has been prepared in

good faith. However, no representation or warranty, expressed or

implied, is made as to the accuracy, correctness, completeness or

adequacy of any statement, commentary, opinions or other information

contained in this presentation.

Disclaimer

Chargemaster & Reimbursement

Strategies

Data Mining – what internal

reports are key

Chargemaster automated charge

capture processes

Chargemaster Maintenance and

Updates

Tools to Stop Revenue Loss

“If hospitals improve financially, it will most

likely be due to improved operations rather

than increased investment returns.”

Fitch IBCA, Duff & Phelps

www.fitchratings.com

Financial Forecasts

What is a charge description master (CDM)?

Menu of all services and

supplies/implants/pharmaceuticals provided by the

facility, usually listed by department

Charge Description Master- What Is It?

• Department #

• Item #

• Internal description

• Patient-friendly description

• Price

• CPT/HCPCS code

• Revenue code

Common Information In The Chargemaster

Multiplier, Unit of Service,

Can also reside in the

• Department #

• Item #

• Price

• CPT/HCPCS code

• Revenue code

• Hospital‐specific

• Revenue centers vs. cost centers

• Typically equates to general ledger (GL) number

• Link between department and charge code for revenue and usage reporting

• Dept # can be included in charge code # but varies by system, e.g., Epic, Cerner, Meditech, McKesson

• Department #

• Item #

• Price

• CPT/HCPCS code

• Revenue code

• Unique line‐item identifier

• Can include CPT/HCPCS #

• May or may not be department specific

• Interface between order entry and billing

May be also known as:

• Charge Code

• Line‐item number

• Financial Item Number (FIN)

• Department #

• Item #

• Price

• CPT/HCPCS code

• Revenue code

• Limitations based on Field

length restraints

• Pros and cons of description

standardization

• Clinically relevant descriptions

• Represents CPT/HCPCS

descriptions

• Patient friendly descriptions

• Supports hard‐coded

CPT/HCPCS

• Department #

• Item #

• Price

• CPT/HCPCS code

• Revenue code

• Mortuary preparation charge

• Cadaver bags

• Enema can & tubing

• TB skin tst results pos

• Deodorant colostomy

• Tonsil wires

• Booklet-brain attack

• Mitt wash pink

• Department #

• Item #

• Price

• CPT/HCPCS code

• Revenue code

With increased transparency pressure, there are a variety of different approaches to annual rate changes among hospitals around the country

If a peer facility elects to decreased rates by 1 percent each year while your hospital increased by 5 percent, your hospital’s rates would be about 35 percent higher than the peer in five years

• Hospitals are increasingly challenged with pricing

pressures, which has resulted in a variety of strategies

• While many hospitals are increasing rates well above

that average, a large portion are making strategic

decisions to lower overall rates of change

Pricing Strategies

In the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28169), we reminded hospitals of their obligation to comply with the provisions of section 2718(e) of the Public Health Service Act. We appreciate the widespread public support we received for including the reminder in the proposed rule. We reiterate that our guidelines for implementing section 2718(e) of the Public Health Service Act are that hospitals either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or their policies for allowing the public to view a list of those charges in response to an inquiry

Pricing Strategies

Patient Friendly Descriptions

Gross Revenue – Analysis of Charge Structure

Mcare Reimb

Cost Tiers

Supplies

Mark-up

Average

Sample

(Hospitals)

< $5.00 5.30 1.75 to 24.57

$5.01 - $10.00 5.25 1.75 to 21.70

$10.01 - $20.00 4.86 1.75 to 21.70

$20.01 - $50.00 4.57 1.75 to 18.60

$50.01 - $100.00 4.14 1.50 to 13.00

$100.01 - $500.00 3.68 1.25 to 10.92

$500.01 - $1,000.00 3.19 1.25 9.73

> $1,000.01 2.82 1.25 to 9.73

Supplies Mark-

up Range

Pricing Strategies - Supplies

Sample of mark-up formula used for medical/surgical supplies:

Implantables are often marked up “costs” x 4

Pricing Strategies - Procedures

Methodology #1 Methodology #2

Medicare APC Rates◦ Multiply x 2 – 4

◦ Defensible

◦ Difficult to price procedures

that are “packaged” by Mcare

Cost Strategy◦ Overhead costs

◦ Salaries for staff

◦ Routine supplies

◦ Time involved

Apply mark-up formula to

obtain charge

Pricing Strategies - Procedures

Methodology #3 Methodology #4

Set charges at 50th - 75th

percentile of facilities in

geographic area

Purchase MedPar Data◦ Obtain commercial claim

Strategic Price Analysis◦ Does include selected

facility pricing data

◦ Includes commercial payer contract considerations

◦ Sometimes across-the-board price increases not best return, selective procedure prices can increase or decrease

• Average Wholesale Price (AWP)

• Average Sales Price (ASP)

• Acquisition costs – apply mark-up formula

• Watchful for self-administered drugs

• Over-the-counter medications

• Source for Patient dissatisfaction

Pricing Strategies - Pharmacy

• Department #

• Item #

• Price

• CPT/HCPCS code

• Revenue code

Claims processing

For outpatient claims, certain revenue codes require CPT/HCPCS

Payment—reimbursement

Regulatory requirements

Decision to hard-code or soft-code

Recommend charge to be reported for each CPT or HCPCS code reported

• Department #

• Item #

• Price

• CPT/HCPCS code

• Revenue code

The intent was to describe:

• What was performed versus where it was performed:

• In OPPS, Medicare does not recommend reportable revenue code

• Report where the cost resides/procedure performed

• May be payer-specific

• Professional vs Technical

Used for:

• Organization of charge data

• Pipeline to the cost report

025X Pharmacy027X Medical supplies/devices

Revenue Code 0278, Implantables do require HCPCS by some commercial payers

037X Anesthesia0390 Blood storage/processing071X Recovery room0762 Observation0942 Education & training services

Revenue Codes Not Requiring a CPT/HCPCS Code for Billing

Revenue Code Selection

• Uniform Code Editor:

• National revenue code recommendation

• Medicare states:

• Facility can report the procedure using the revenue code that represents where the procedure was performed (costs follow revenue)

Colonoscopy RC 0360 Operating room

Colonoscopy RC 0750 GI laboratory

Colonoscopy RC 0761 Treatment room

Colonoscopy RC 0450 Emergency room

UB-04 Claim Form

Chargemaster data

reported in this

section of the claim

FL #42, Revenue Code

Revenue Codes Requiring HCPCS

(Partial List)

FL 43—Description

0324 Radiology Chest X-ray

• The hospital’s description of the service provided

• Usually reflects the revenue code description:

• Pharmacy

• Supplies

• X-ray

• CT scan

• Emergency room

Form Locator 43—Description

FL 44—HCPCS/Rates

0324 Radiology Chest X-ray 71020

• The CPT or HCPCS code that reflects the service being provided:

• CPT —Five-digit numeric defined by AMA

• HCPCS—Five-digit alphanumeric defined by CMS

• Modifiers also go in this field:

• Two-digit number, letters, or alphanumeric that provides additional information about the CPT or HCPCS code it is reported with:

• RT- Right LT- Left 91- Repeat lab test

• UB-04 accommodates four modifiers

• A total of 13 digits

FL 44—HCPCS

FL 45—Service Date

0324 Radiology Chest X-ray 71020 032517

• The date the service was provided

• Is specific to each revenue code reported on the claim

• This date must coincide with the dates in FL 6 Statement

covers period

• Will determine payment rate related to the quarterly

updates in APC program

FL 45—Service Date

FL 46—Service Units

0324 Radiology Chest X-ray 71020 032517 1

• The number of times the service was provided.

• Service codes typically are a 1—one ER visit, one Chest

• Supplies could be numerous—if six different supply items

were used, then a unit of 6 would be reported with

revenue code 027X

• Pharmacy is often more than 1 unit

• Time-based procedures are typically more than 1 unit

• Effects on reimbursement:

• HCPCS code J9065 is Cladribine per 1 mg

• National reimbursement is $20.91

• Physician orders 5 mg therefore 5 units of J9065 should

be reported with a resulting reimbursement of $104.45

• Revenue Code 0636

FL 47—Total Charges

0324 Radiology Chest X-ray 71020 032517 1 75 00

• Charges per service reported

• The total charges should be added up at the bottom of the

field and be associated with revenue code 0001

• Charges are set by the facility

FL 47—Total Charges

FL 48—Noncovered Charges

0324 Radiology Chest X-ray 71020 032517 1 75 000637 Pharmacy-Self Admin 032517 3 15 75A9270GY

Should reflect charges incurred by the

facility that you know are not covered

by Medicare:

◦ Self-administered drugs (RC 637)

◦ Patient convenience items (RC 99X)

◦ Items not meeting medical necessity

(Modifiers based on obtaining ABN)

FL 48—Noncovered Charges

• Who maintains the CDM?

• Revenue Integrity

• Clinical assistance

• Coding contribution

• Billing input

• Financial involvement

• Compliance support

Close communication with

clinical departments

Audit to determine what

was ordered, performed

and billed is consistent

Who Maintains the Chargemaster-The Team

Initiate

Revenue Integrity-Managing the Chargemaster

Workflow

Requests for procedure, supply, pharmaceuticals received

from clinical departments

Quarterly and annual updates

Disseminate regulatory updates

Continual and open communication with ancillary

departments, PFS and HIM

Initiate Audits

Workflow

Confirms all charge lines appropriately utilized

Periodically focuses on specific departments for charge

capture accuracy and provides education as necessary

Reviews frequency of CCI edits and/or claim rejections from

Validates projected revenue for clinical areas

Retains compliance for governmental billing

Initiate Interface

IntegrityAudits

Workflow

Charge Capture Chargemaster

Chargemaster Coding

Coding Billing

Initiate AuditsInterface

IntegrityEducation

Workflow

Ancillary staff relies on Revenue Integrity for answers to

questions on how to charge, reimbursement questions and

operational options

Provides education for annual coding and reimbursement

updates

• Billing input

Engage clinical department

expertise to review specific

chargemasters

More minds are better than

Department’s area of

business

• Billing input

Determine what

procedures should be hard-

coded/soft-coded

Assignment of modifiers

Work NCCI edits

Review MUE edits

Assigns modifiers, e.g.

modifier -59

Chargemaster vs. HIM Coding

Chargemaster coding or HIM coding (“hard” vs. “soft” coding)?-

- Surgery - Emergency room - Endo suites

- Clinics - Cardiac cath -Interv. radiology

HIM typically codes major surgery (CPT 10000 — 69999)

CDM Number Billing Description G/L Key CPT R.C.

43000108 I&D SUBCUT ABSC SIMP 630 10060 450

43000207 I&D SUBCUT ABSC COMP 630 10061 450

43000306 I&D PILONIDAL ABSC 630 10080 450

70210034 MAJOR SURG LEVEL 1/1ST HR 702 - 360

70220033 MAJOR SURG LEVEL 1 EA ADDL 15 MIN 702 - 360

70230032 MAJOR SURG LEVEL II /1ST HR 702 - 360

70240031 MAJOR SURG LEVEL II EA ADDL 15 MIN 702 - 360

70250030 MAJOR SURG LEVEL III/1ST HR 702 - 360

70260039 MAJOR SURG LEVEL III EA ADDL 15 MIN 702 - 360

70210042 MINOR SURG CANCEL CASE 702 - 360

Chargemaster vs. HIM Coding

Manual Manipulation of UB-04 Claim Data

Reimbursement . . .

Screening and Diagnostic procedure on same claim form should

generate CCI edits

• Share chargemaster with HIM coding staff:

• Eliminates duplicate work

• Avoids potential double reporting

• Ensures continuity of reporting procedures and proper revenue

• Create “Who Codes For What” Policy

• Specific for each department

• CPT Code range

• Include HCPCS

Coding Decisions

• Billing input

Communication remains

open for payer denials

Revenue Code rejections

Non-covered procedures

Inpatient/Outpatient

• Billing input

Contract Management

communicates details

Carve-out specific

revenue codes

Coverage policies

• Billing input

Compliance kept in loop for any billing or coding issues identified

Review RAC initiatives

Review OIG Work Plan

Review OIG audits

Regulatory expertise

Responsibilities can include charge auditing, process improvement and reimbursement auditing independent of RI Dept

Identified Revenue Opportunities Easily Recognized By Analyzing Revenue and Usage Data

Procedures with One-to-One Reporting

Speech-Pathology Procedure

Radiology Procedure

• CPT 92611 Motion

fluoroscopic evaluation of

swallowing function by cine

or video recording

• 74230 Swallowing function,

with cineradiography/

video-radiography

Speech Pathology Evaluation and Fluoroscopy

SIM Code FIM Code SIM Description

Primary

Volume

Default

CPT/HCPCS

15155 792015155 ST VIDEO SWALLOW STUDY $350.00 854 371 1225 92611GN

42307 770042307 RA MODIFIED BARIUM SWALLOW $1,155.00 648 371 1019 74230

TOTAL 206 206

Calculations for Gross Revenue Opportunity Identified for Inpatients

Radiology Missed 206 Videography Procedures, each with a charge of $1,155

$1,155 x 206 = $237,930

Speech Pathology Evaluation and Fluoroscopy

• Net Reimbursement Quantification can be a challenge:

Payer How Paid Payer Mix Net Reimbursement Oppor

Medicare MS-DRG 49% No Add'l Net Reimbursement

Medicaid Case Rate 15% No Add'l Net Reimbursement

BC 5% Charges 10% $1,190.00

UHC 8% Charges 5% $952.00

Self Pay 3% $3,570.00

Other 18% No Add'l Net Reimbursement

TOTAL $5,712.00

• CPT 36600 Withdrawal of arterial blood

• Status Indicator Q1

• Reimbursement is $91.18

• Requires more effort and risk than a simple

venipuncture (which is paid separately under clinical

laboratory fee schedule)

Respiratory Therapy-Arterial Collections

Arterial Puncture reported by Respiratory Therapy

Arterial Blood Gas Analysis performed by Lab

One-to-one correlation except when drawing

specimen from established arterial line

Revenue Code 920 for CPT®

Dept Chg # Description Charge

Volume

Resp Ther 780015509 THERAPIST ABG DRAW $135.00 6260 344 6604 36600

Lab 753037161 VENOUS BLOOD GASES $223.00 221 20 241 82803

Lab 755010058 BLOOD GAS POINT OF CARE $223.00 2950 19 2969 82803

Lab 753037153 ARTERIAL BLOOD GASES $223.00 4151 305 4456 82803

Volume

TOTAL 7101 324 7666

Missed Procedures 1062

Not all specimen collections are obtained via arterial puncture. Nursing/Respiratory

Therapists may collect from an established arterial catheter, see CPT 37799

If the missing procedures shown above represent the specimen collections obtained from an

established arterial catheter, we need to include those procedures in the analysis

To quantify gross revenue for the above missing specimen collections:

Missing procedures 542 x Charge of $135.00 = $73,170

Volume

TOTAL 7101 324 7666

Nursing

Svs 638456451 SPECIMEN COLL EXIST CATH $223.00 520 520 37799

MISSING PROCEDURES 542

Respiratory Therapy – Other Procedures

• Cardiopulmonary Resuscitation

• How many charged by department versus charged

by emergency department

• Any other department have access to charge lines

to also charge?

• Reportable one time per episode

• Reportable by a single department

• The professional follow-up services are typically captured in the

physician’s global period and not separately reportable. However, for

the technical charges, the hospital does not have a global or follow-up

period and each patient encounter may be separately charged. Based

on previous fiscal year’s data the facility has the gross revenue

opportunity as shown below:

Actual Chargemaster Audit Results

Emergency Room

• 99281 57,180

• 99282 86,311

• 99283 204,218

• 99284 73,881

• 99285 75,774

• 99291 4,360

• Total 501,724

Bell Curve-Technical Component E.R.

100000

150000

200000

250000

300000

Evaluation and Management Codes

s9928599284992839928299281

Emergency Room: Inappropriate Bell Curve

Series1 2,258 5,893 1,828 386 28 42

1 2 3 4 5 699281 99282 99283 99284 99285 99291

ER Volume

YTD OP

Qty Var. Projected

Charge

Additional

Revenue Proj

99281 2,258 -1,500 758 $75 -$112,500

99282 5,893 -4,000 1,893 $139 -$556,000

99283 1,828 4,200 6,028 $209 $877,800

99284 386 950 1,336 $345 $327,750

99285 28 250 278 $378 $94,500

99291 42 100 142 $807 $80,700

10,435 0 10,435 $712,250

Emergency Room: Projected Gross Revenue

• Hospitals are required to use HCPCS code 99291 to report

outpatient encounters in which critical care services are

furnished. The hospital is required to use HCPCS code

99291 in place of, but not in addition to, a code for a

medical visit or for an emergency department service.

• CPT 99291 Critical care, evaluation and management of

the critically ill or critically injured patient; first 30-74

minutes

• CPT 99292 Critical care, evaluation and management of

the critically ill or critically injured patient; each additional

30 minutes (List separately in addition to code for primary

service)

Emergency Room-Critical Care

Charge

Code Charge Description

Code Price

27810F CLSD TX BIMAL ANKL FX W MANIP 450 $253.10 27810

27816F CLSD TX TRIMAL ANKL FX WO MANIP 450 $253.10 27816

27818F CLSD TX TRIMAL ANKL FX W MANIP 450 $253.10 27818

27830F CLSD TX PROX TBF DSLC WO ANESTH 450 $253.10 27830

27842F CLSD TX PROX TBF DSLC W ANESTH 450 $1,092.10 27842

27840F CLSD TX ANKLE DISLOC WO ANESTH 450 $253.10 27840

30905F CONTROL OF NOSEBLEED 450 $258.55 30905

30906F REPEAT CONTROL OF NOSEBLEED 450 $258.55 30906

31500F INSERT EMERGENCY AIRWAY 450 $524.75 31500

31505F LARYNGOSCOPY;INDIRECT DX 450 $146.20 31505

31511F REMOVE FOREIGN BODY LARYNX 450 $146.20 31511

31575F LARYNGOSCOPY;FLEX F/O DX 450 $63.30 31575

Emergency Room-Hard Coded CPT Codes

Charge

Code Charge Description

Code Price

2307867 ER PROC ORTHO LEVEL 1 450 $350.00

29243865 ER PROC INTEGUMENTARY LEVEL 1 450 $175.00

56179863 ER PROC OCCULAR LEVEL 1 450 $100.00

83115861 ER PROC DIGESTIVE LEVEL 1 450 $300.00

Emergency Room-HIM Assigned CPT Codes

Emergency Room-Procedure Charge Methodologies

Chargemaster-Hard Coded HIM-Assigned CPT Codes

• Each procedure contains individual charge line with charge

• Easier to audit charge capture process

• Charge capture processes often easier

• Increased gross revenue when converting to this model

• Charge platform more generic

• Charges may be below the Medicare APC amount

• Often have missed charges if multiple procedures performed

• HIM-assigned CPT codes may be reported with incorrect procedure charge line

Clinic Encounters – Commercial vs Medicare

Commercial Payers Incl Medicaid Medicare

Description

Volume

Clinic Visit Level 1 New/Est 12530

TOTAL 13865

• G0463, Hospital outpatient

clinic visit for assessment

and management of a

patient

• A single charge for any

Medicare encounter fails to

show resource

consumption and costs

Imaging Components

• Radiology S&I RC 320

• CT guidance RC 350

• MRI guidance RC 610

• Ultrasound guidance RC 402

Surgical components

• One-to-one relationships

• Complex cases

• Revenue code 360/361 or RC 320, 350, 610 or 402

Interventional Radiology

CPT Description 2014 2015 2016 Charge APC

73040 Shoulder arthrography 150 31 85 $280

23350 Injection Shoulder arthrog 113 16 60 $237 Status "N"

Missed Procedures 37 15 25 Status "N"

Missed Gross Revenue $8,769 $3,555 $5,925 $18,249 Status "N"

73580 Knee arthrography 0 0 14 $265

27370 Inj knee arthrography 0 0 0 $200 Status "N"

Missed Procedures 14 Status "N"

Missed Gross Revenue $0 $2,800 $2,800 Status "N"

73525 Hip arthrography 31 0 43 $188

27095 Inj hip arthrography 0 0 18 $202 Status "N"

Missed Procedures 31 25 Status "N"

Missed Gross Revenue $6,262 $5,050 $11,312 Status "N"

Three Years Gross Revenue Opportunity $32,361

Interventional Radiology

74455 Urethrocystography voiding 146 55 95 $217

74430 Cystogram min 3 views 62 0 77 $205

51600 Inj urethro voiding 77 26 85 $241 Status "N"

Missed Procedures 131 29 87 247 Status "N"

Missed Revenue $31,571 $6,989 $20,967 $59,527 Status "N"

74450 Urethrocysto retrograde 28 25 26 $242

51610 Inj Urethrocysto retro 0 0 0 $200 Status "N"

Missed Procedures 28 25 26 79 Status "N"

Missed Revenue $5,600 $5,000 $5,200 $15,800 Status "N"

• OCE Edit # 43

• Transfusion or blood product exchange without

specification of blood product

• Generated when

• A blood transfusion or exchange is coded but no

blood product is coded

• May occur when blood product charges posted on

wrong date of service or incorrect patient encounter

Blood Administration, OCE Edit Billing Issues

Create a backward edit so that:

• Outpatient:

• When a blood product is coded and reported on the claim, a transfusion or exchange must also be on the claim

• Inpatient:

• When revenue code 38X or 390 is on the claim, expect to also see revenue code 391 also reported

• Accuracy of revenue code assignment in chargemaster is important

Blood Administration, OCE Edit Billing Issues

Blood Administration Analysis

Chg # Charge Description Charge

Utilization

757016671 PLT PHER LR QUAD IRR $1,085.00 1 0 1 P9037

757011353 CRYOPRECIPITATE 5 UNIT POOL $640.00 44 0 44 P9012

757023668 LRPC $451.00 1822 821 2643 P9016

757023189 PLATELETS PHERESIS LEUKORED REDUC$1,425.00 356 135 491 P9035

757023205 PLATELETS PHERESIS LEUKOCYTES RE $1,830.00 61 20 81 P9037

757016669 LRPC QUAD IRRAD $566.00 1 0 1 P9040

757023221 LRPC IRRAD $698.00 87 18 105 P9040

757022850 FRESH FROZEN PLASMA $167.00 1115 503 1618 P9059

TOTAL 3487 1497 4984

On “Average”, each transfusion service averages approximately two blood

products per administration

Calculation then demonstrates the facility should have approximately 1,743

transfusions for inpatients and 748 transfusion charges for outpatients

Chg # Charge Description Charge

Utilization

608013282 NB BLOOD ADMINISTRATION $1,200.00 3 0 3 36430

785013029 BLOOD ADMINISTRATION $1,200.00 0 0 0 36430

TOTAL 16 472 488

It appears the facility missed 1,727 administration charges for inpatients and

276 charges for outpatient encounters

Charge Description

Utilization

Utilization Total Util

Reported Blood Products 3487 1497 4984

Two products per administration 2 2 2

Reportable Transfusion Procedure 1743.5 748.5 2492

Reported Transfusion Services 16 472 488

Missed Transfusion Procedures 1727.5 276.5 2004

Charge for Transfusion Procedure $1,200 $1,200 $1,200

Gross Revenue Opportunity $2,073,000 $331,800 $2,404,800

Charge Capture Processes and Use of Technology As A Helpful Tool

• There are different ways that charges are reported

• Charge to drop as soon as an order is documented

• When drug or supply removed from Pyxis or Omnicell

Drug charge drops upon administration

• Charges will often not drop unless the test has been read and the results dictated

• Charges generated when documentation completed

• Batch entry – manual keying of charges

• Explode/linked charges generate multiple charges that are routinely performed

Charge Capture Processes

Charge Panels, Explodes or Links

• There are two distinct ways to assess the effectiveness of

charge capture processes, both of which are necessary

for ensuring optimal results

• Chart auditing which identifies lost charges but rarely

remediates root causes

• Technology which can identify potential missed charges more

efficiency and comprehensively than the traditional sample-

based chart auditing techniques

• Can help reduce charging errors over time

Manual versus Automated Processes

• When charge capture improvements occur, the

net revenue impact will be recognized

• Analyze payer mix, contracts, carve-outs, add-ons,

outliers, implants, high-dollar drugs, with some

consideration for productivity measures

Manual versus Automated Processes

Recommended ResourcesTools of the Trade

Medicare contractor bulletins and advisories

Medicare manuals:

◦ Claims Processing Manual (combination of the old hospital, intermediary, and carrier manuals)

◦ Benefit Policy Manual

◦ Provider Reimbursement Manual

◦ National Coverage Determinations Manual

Transmittals

Office of Inspector General

Audits and Work Plan

NCCI edits (National Correct

Coding Initiative edits)

Coverage determinations

Addendum B

Internet Resources

Medicare’s Main Website http://www.cms.hhs.gov

• Uniform Billing Editor, Optum360

• CPT ® 2017―AMA

• HCPCS 2017―Medicare-specific codes

• Coders’ Desk Reference, Optum360

• CPT ® Changes: An Insider’s View―AMA

• Hospital Chargemaster Guide, Various Publishers

• CPT Assistant―AMA

• Software Products

Additional Resources

Decisions:

◦ Make chargemaster Medicare compliant?

Yes―Elimination of nonreportable procedures

and charge lines. May leave money on the table

No―Bill other payers

Facility must ensure nonreportable charges are

NEVER submitted to Medicare as covered services:◦ Computer edits typically only fail-safe methodology

Structure of the Chargemaster

Self Pay and

Others

Managed Care

Cross/Commercial

Medicaid

Medicare

Median Payer Mix

SER VIC E

C OD E D ESC R IP T ION R EVISED D ESC R IP T ION P R IC E R .C .

R .C . H C P C S

H C P C S M C A ID

M C A ID

731846 B A LLOON D IA LA T ION C A T H ET ER S 630.25 621 272 C 1726 Y7107

731847 B ILIA R Y ST ON E R EM OVA L B Y T T UB E 1,354.00 320 74327 74327

731848 B IR D S N EST F ILT ER 1,320.00 621 278 C 1880 Y7107

731849 B ON E B X SUP ER F IC IA L 176.00 361

731850 B X LUN G/ M ED IA ST IN UM 176.00 361

731851 EXC H A N GE GUID EWIR E 88.25 621 272 C 1769 Y7107

731852 F EM OR A L R UN OF F (UN I) 986.00 320 75710 75710

731853 F EM OR A L R UN OF F A R T ER IO (B I) 1,427.00 320 75710 75716 75710 75716

731854 M R A A B D OM EN M R A A B D OM EN WO C ON T 1,100.00 610 74185 C 8901 74185

731855 M R A C H EST M R A C H EST WO C ON T 1,100.00 610 71555 C 8910 71555

731856 M R I C H EST M R I C H EST WO C ON T 1,068.00 610 71555 C 8910 71555

731857 M R A A B D OM EN W&W/ O C ON T 1,363.00 610 74185 C 8902 74185

731858 M R A A B D OM EN W/ C ON T 1,213.00 610 74185 C 8900 74185

Chargemaster Accommodating Additional Payer Requirements

• Mastering change is key element for success

• 2017 offers new challenges

• Good luck!!!

Final Thoughts

Glenda J. Schuler, RHIT, CPC, COC

• Vice President, Revenue Cycle Solutions, for HCS HealthCare Consulting

Solutions

• AHIMA-Approved ICD-10-CM/PCS Trainer

• Over 39 years experience in billing, coding, chargemaster, CPT, revenue

cycle, compliance

• National speaker for AAPC, AHIMA, state hospital associations, state

HIMA chapters, VHA/Vizient, HFMA and other organizations specific for:

• Ambulatory Payment Classifications

• Chargemasters

• OCE Editor and CCI reporting

• Modifiers

• gschuler@hcsglobal.net

Biography:

•Since 1996 HealthCare Consulting Solutions (HCS) has provided a broad spectrum of services and solutions in revenue cycle management, chargemaster maintenance, coding, documentation, reimbursement/billing, compliance and education/training for hospitals and physician practices, including:

• Inpatient (MS-DRGs), Outpatient (APCs) and Physician Practice Due Diligence & Compliance Risk Assessments including RAC, CERT, ZPIC, MAC/Carrier & OIG target areas

• CAH and Rural Health Clinic Compliance Audits and Education/Training

• DMEPOS Reviews, Operational Assessments and Education/Training

• IRF, IPF, SNF, HHA and Hospice Reviews

• Physician Documentation Assessments and Education/Training

• Revenue Cycle and Business Operations Assessments (Physician and Facility)

• Comprehensive Chargemaster Analysis, Supply and Pharmacy Assessments

• Strategic Pricing and Clinical Profile Assessments

• Client-Specific Educational Workshops and Conferences

• ICD-10-CM/PCS Education – Providers and Coders

HealthCare Consulting Solutions

For additional information on our consulting and education/training solutions, please contact:

Jeff Neustaedter, President

HCS HealthCare Consulting Solutions

800.659.6035

816.309.8600 Cell

jneustaedter@hcsglobal.net

www.hcsglobal.net

For Additional Information:HealthCare Consulting Solutions

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