Charge Description Master and Revenue Integrity: Putting the Pieces Together Presented by: Catherine (Kate) H. Clark, CPC, CRCE-I Vice President Maryland

Charge Description Master and Revenue Integrity:

Putting the Pieces Together

Presented by:Catherine (Kate) H. Clark, CPC, CRCE-I

Vice PresidentMaryland AAHAM, Past President

Page 2

Objectives

This presentation will define and promote understanding of the following:

Charge Description Master (CDM) DefinedRevenue Integrity DefinedCDM Management OptionsRevenue Integrity, CDM, and the Revenue Cycle – How can we do it better?

Page 3

Polling Question #1

Respond to what role you play in relationship to the CDM/Revenue Integrity for your current position.

CDM Coordinator/ManagerCFO/CIO/COO/CEORevenue Cycle StaffFinance/Reimbursement StaffContractingCare/Case Management/CDI/DenialsOther

Page 4

Why Now?

Transition from Inpatient to Outpatient– Outpatient visits doubled from 1990-2010 (50%)– Inpatient admissions grew by 13%– Outpatient charges impacted by charge capture (% of charges =

Reimbursement)

Charge Capture Matters– Additional reimbursement– Accurate calculation of costs– Revenue Tracking by Department

Page 5

Why Now?

Electronic Medical Records (EMR)– Cleaning Up before EMR is built– Preparation = Less Clean-up– Crosswalk of a “constant” current state to EMR build– Departments are responsible for Reconciliation (Revenue

Integrity?)

Timing and Resources– January, October– Contracting updates for Non-Medicare payers– Updated Coding Guidelines– APC and HSCRC Updates

Page 6

Polling Question #2

In your opinion, what is the most important function of the CDM?

Charge CaptureComplianceDenials ManagementMedical Necessity VerificationPoint of Service CollectionsAccurate Claim SubmissionNone of the AboveAll of the Above

Page 7

CDM Defined

Charge Description Master (CDM)– A comprehensive listing of items billable to a hospital patient or

patient’s health insurance provider.

Master file built within the hospital information systems which is designed to interface with other software applications to support billing and reporting.Fields include (but are not limited to): – Revenue codes– Current Procedural Terminology (CPT) or HealthCare Procedural

Coding System (HCPCS)– Pricing– Service descriptions– Relative Value Units (RVUs) when applicable– Payer Specific Data Elements

Source: http://en.wikipedia.org/wiki/Chargemaster

Page 8

CDM Defined

CDM and the Claim Form

Has been described as “the central mechanism of the revenue cycle” of a hospital.

The CDM is closely linked to revenue generation. It is fundamental to the charge capture process.

Many CDMs are now being used as a component of revenue integrity validation.

Page 9

Revenue Integrity Defined

Purpose: to prevent recurrence of issues that can cause revenue leakage and/or compliance risk.

• Revenue Integrity focuses on process improvements

• Revenue Integrity provides a check/balance system for the revenue cycle components, with support from

leadership and technology.

Revenue Integrity– Stand-alone Department– Corporate Initiative– Organizational Structure

Page 10

Components of CDM/Revenue Integrity

Charge Master

CPT/HCPCSRates/PricingUnits of Service

ReimbursementPPS & Fee Schedules

General LedgerSupply Chain & Pharmacy Mgmt

Knowledge: Billing & Clinical

Complete & Correct Information = Paid Claims

Page 11

CDM Management Options

Components to Consider• Risk• Relationships• Compliance

CDM Team• Meeting Attendance – enforced by leadership

– Mandatory

• Composition of the Team– Who participates

• CDM Team Titles and Roles• CDM Staff

– Translator-Explanation of Roles– Manager– Coordinator– Analyst– Finance Staff

Page 12


Characteristics of effective CDM staff• Detail oriented• Inquisitive• Relentless• Highly organized• “Even” disposition• Good written and verbal communication

skills• Quick

Page 13

CDM Management Options – Set-Up

New Line Item Creation– Clinical– HIM– Rates and Reimbursement– Contracting– PFS– Financial Counseling/Patient Access

– Sign-Off of New Line Item by Impacted Areas• Are services provided billable? • Do they translate to CDM line items?• Each Department to sign-off (see above) must contribute with

their piece of the puzzle

Page 14


Enterprise vs. Single-Entity CDM Management– Size of CDM– Order Entry mapping to correct CDM lines

• Problematic for both entities, but moreso for Enterprise CDM

– Fee Schedule Management within CDM• Updates

– Multiple facility or enterprise builds with dedicated staff vs. single entity staff who are responsible for multiple roles.

– Electronic Health Record – controlled by whom– Are providers Regulated and Non-Regulated

Page 15


Internal vs. External CDM Management Options– Review goals of the CDM for organization– Cost of Vendor vs. Cost of Resources– Coordination of Information – NCD, LCD, Contracts– Implementation of changes– Communication with clinical staff– Information Technology interfaces– Data validation– Which option saves time or are more valuable?

Page 16

Revenue Integrity and Revenue Cycle

CHARGE CAPTURE

•MD ORDER ENTRY•SCHED & REG•ORDER ENTRY

BILLING•PAYER TABLE•CPT CODE•REV CODE •PRICING•RVU

HIM

•CPT CODES

BILLING ============PAYMENT=============PFS

Page 17

Revenue Integrity, CDM, & Revenue Cycle

CDM = Cash Flow– Updated CDM leads to faster cash

Scheduling– Clinical tests are scheduled based on CPT Codes– Patient balances calculated at time of scheduled procedure

Advanced Beneficiary Notice (ABN) Software– ABN executed based on CPT code assigned to test.– CPT is determined by CDM– Estimate patient balances if service is non-covered

• (All non-covered services do not require an ABN)

Pre-Authorization– Services are pre-authorized with insurance companies based on

the CPT code of the service.– Point of care collections – based on CDM pricing

Page 18


Charge Capture – Electronic or Manual– Electronic = Interface of charges through systems– Manual = Direct data entry into billing module

• Both require accurate CDM set-up

– Preference List (clinical charges) to CDM• Charge Entry from Clinical Staff or Charge Staff• Set-up must be determined before Preference list build

– Order Entry Systems – Pyxis, Lab, Radiology, MUSE• Charge triggered based on parameters• Parameters defined by medical center, facility, or provider • Typically requires physician signature, physician order, or

nursing entry

Page 19


Charge Capture – Electronic or Manual– Electronic Health Record (EHR) documentation

• Automatic generation of charges through completed documentation

– Encounter Forms• Completed by provider of care or designee• Manual entry into billing system• Typically direct data entry into billing system

– Professional Fees• Triggered from Facility CDM• Professional Provider CDM

Page 20


UB-04 Claim Form– Billing of services performed to payers– Interface to billing systems or claim scrubber

software– Bridge Routines – what is built behind the scenes

for claim correction in order for them to be submitted to payers as “clean” claims.

Payer Tables– Compare patient insurance to payer information

tables within the CDM to ensure accurate revenue and CPT/HCPCS information on the claim form.

Page 21


Health Services Cost Review Commission (HSCRC) (Maryland Hospitals Only)– HSCRC components are contained within the CDM as RVUs or prices

for drugs and supplies– Rate compliance within each Department reported to the HSCRC

Outpatient Prospective Payment System (OPPS)– Pricing of services based on reimbursement – Bundled services – still built separately in the CDM as needed– Outlier Payments

Denials Management/Cash Posting– Communication of payer needs through denials and interface back to CDM– Denied services are communicated to the provider of care using specific

HIPAA compliant denial codes.– Ongoing denial activity on specific line items must be communicated

back to the CDM Team.– Correct Coding Initiative (CCI) Edits

Page 22


Health Information Management (HIM)– HIM coding of services within the hospital– No linkage to a specific CDM populated with CPT/HCPCS– HIM coded CPT/HCPCS codes must map to the appropriate revenue codes, which are

identified in the CDM. – CDM mapping to specific revenue codes allows HIM coded services to cross to the claim

form

Clinical Staff– Clinicians and Clinical Leadership must be involved with the set-up and

maintenance of the CDM.– Denied services are communicated to the provider of care using specific

HIPAA compliant denial codes.

Compliance– Each CDM that includes CPT/HCPCS, price, and quantity is subject to

evaluation for compliance with billing and coding rules.– Correct Coding Initiative (CCI) Edits– Payer Edits

REG

ULA

TIO

NS

PROCESS

CULTURE

TOOLS

PEOPLE

CDM and Revenue Cycle

BILLING

SCHEDULING

REGISTRATION

INSURANCEVERIFICATION

FINANCIALCOUNSELING

CASE MGMT/QUR

CDM/CHARGECAPTUREMEDICAL

RECORDS

CUSTOMER SERVICE

THIRD PARTYFOLLOW- UP

SELF PAYCOLLECTIONS

PROGRAMADMINISTRATI

ON

CASH POSTING

POSTPAYMENT REVIEW

TECHNOLO

GY

CU

STO

MER

EXPECTA

TIO

NS

PAYO

RS

POINT OF SERVICE

COLLECTIONS

DENIALS MANAGEMENT

FINANCIAL CLEARANCE

Adapted from -Source: http://healthdatamanagement.com/media

/RC101

COMPLIANCE

DependentRelated

Page 24

Revenue Integrity within Revenue Cycle

What is it…– How is it different from Charge Capture (only)– How is it measured?– What tools are used?– How does current workflow or culture impact

revenue integrity?– How do we know it is right?– Accountability– Oversight– Maintenance

Page 25

CDM and Revenue Integrity

Key Strategies• Create staff awareness• Provide tools and/or guidance• Design and implement a process for monitoring• Development of tools• Analysis of results to identify root causes• Develop corrective action plans• Track corrective action plan implementation• Verify improvement• Maintain oversight• Reporting to leadership.

Page 26

Polling Question #3

Has your facility performed a comprehensive CDM review within the past year?

Yes, completed using internal resourcesYes, using an outside firmYes, using both internal resources and outside firmNo, not within the past yearI Do Not Know

Page 27

CDM and Revenue Integrity - Strategies

When are CPT Codes and CDMs Updated– Is there a schedule for general CDM Updates– Outreach to clinical areas– Outreach to PFS

Baseline validation of the CDM by external company– HSCRC review of RVUs for CDM validation– Review of each clinical area ensuring the CDM is accurate– Ensure Operational workflow is supported by accurate CDM set-up

Crosswalks between systems must be up-to-date and accurate (current file maintenance reduces interface errors and manual corrections)– EHR mapping of charges– Interface with HIM– Order Entry mapping to the CDM– Preference Lists mapping to CDM– Charge Documents – including professional fee (in hospital setting)

Page 28

CDM and Revenue Integrity Strategies

Communication– Scheduling, Registration, Pre-authorization– Physicians, clinicians, or other providers– Patient Financial Services (PFS) – Facility and Professional– HIM, Denials, Nurse Auditors, CDI, Care/Case Management

Comprehensive CDM Review– Discussion

Education– Who teaches and relays the material– Who receives and is being trained on the material– What are the details of what is taught– How do you know the information is accurate

Page 29

CDM, Revenue Integrity, and You

What can you do…–Understand the chain of command–Gather Facts – Reports, examples,

data, results of queries–Communication – Not Personal, Direct,

Focused–Ownership of Findings–Follow-Up–Follow- Up (x2) if Issue Not Closed–Doing the Work vs. Doing it Well

Page 30

Final Comments

Reimbursement Methodology– Does not change the need for a compliant and current CDM and Revenue

Integrity Plan.

Updating the CDM– Policies and procedures– Code updates (at least 1x per year)– Inactivating or Added Services

Compliance Plan– Once a CDM policy and procedure is documented (frequency of review,

how new line items are created, consolidating the CDM), it must be followed.

– Revenue Integrity directly ties to compliance

Comment in Closing: – Stay current or you will never catch up

Questions

Thank You!

31

Catherine (Kate) Clark, CPC, CRCE-IVice President

Past President, Maryland [email protected]

(410) 979-1624

Kohler HealthCare Consulting, Inc.www.kohlerhealthcareconsulting.com

(410) 461-5116 – Office

mailto:[email protected]

http://www.kohlerhealthcareconsulting.com/