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Ensuring Accuracy: Chargemaster and
Outpatient Facility Coding
Catrena L. Smith
CCS, CCS-P, CPC, PCS
DisclaimerThis material is provided as education for coders and other
personnel involved in the coding or chargemaster process. Every attempt has been made to ensure that accurate information is
presented. Government regulations, as with coding can be ever-changing. There can be no assurance that guidance will not change.
"CPT® copyright 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical
Association.“
“Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT® , and the AMA is not recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.”
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Overview
• Define Charge Description Master and identify why
it is important in the outpatient facility setting
• Identify elements of a chargemaster
• Identify items/services that should be reviewed to
ensure revenue integrity
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Charge Description Master
• Includes a list of:
– Description
– Services
– Procedures
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Charge Description Master
• Includes a list of:
– Supplies
– Drugs/biologicals
– Radiopharmaceuticals
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Charge Description Master
• Includes a list of:
– Revenue codes
– GL number
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Charge Description Master
• CDM number is the charge code (i.e. 6051220)
• The charge code represents– Charge Description
– CPT or HCPCS code(s)
– Revenue Codes
– Charge amount
– Identifies the department
– May contain modifiers
– GL number/GL key
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Charge Description Master
• Not all CDM numbers/charge codes are tied to a
cost.
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Why is the CDM important
• Aids in timeliness of coding and billing
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Why is the CDM important
• Aids in ensuring all necessary elements for a line
item are assigned
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Caution
BEWARE: The most accurate chargemaster does not
guarantee that there will be no errors.
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How does the chargemaster effect outpatient
facility coding?
• Codes are assigned via the CDM
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How does the chargemaster effect outpatient
facility coding?
• Procedure(s) unlikely with diagnosis code(s)
assigned
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How does the chargemaster effect outpatient
facility coding?
Diagnosis code: 788.30 (Urinary incontinence,
unspecified)
Procedure code: 57288 (sling operation for stress
incontinence)
*Procedure is unlikely with diagnosis code assigned
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How does the chargemaster effect outpatient
facility coding?
• Multiple procedures or services
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Area of Review
• Medication administration
– Injections
– Infusions
• Vaccinations
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Area of Review
• Medication Administration
– Medical records documentation
– Type of injection/Infusion
• Diagnostic
• Therapeutic
• Chemotherapeutic
• Location
• Modifier -59
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Medication Administration- Hierarchy
Chemotherapy
Diagnostic, prophylactic, and therapeutic
Hydration
Infusions
Pushes
Injections
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Area of Review
• Medication Administration
– Time documentation
– Total time
– Start/Stop time
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Area of Review
• Medication Administration
– Multiple initial services
• Same clinic location
• Different clinic locations
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Area of Review
• Medication Administration
– Drugs/materials
– Supplies/tubing
– Local anesthesia
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Area of Review
• Vaccinations
– Administration
– Vaccine Product
– Multiple vaccines
– Multiple departments
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Area of Review
• Vaccinations
– Carrier rules
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Area of Review
• Vaccinations
– HCPCS vs. CPT
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Area of Review
• Vaccinations
– Diagnosis code Procedure Code compatibility
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Area of Review
• Transfusion services
– Laboratory
– Blood Products
– Transfusion
– Department (i.e. ED, Clinic, Infusion Center,
Observation ward, etc.)
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Area of Review
• Pain Management Injections
– Procedure type
– Number of levels
– Fluoroscopic guidance
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Area of Review
• Biopsies
– Single mass/lesion
– Multiple masses/lesions
– Single specimen sent for pathological analysis
– Multiple specimens sent for pathological analysis
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Area of Review
• Biopsy Documentation
– Chargemaster
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Area of Review
• Destruction of lesions
– Type of Lesion
– Location
– Number treated
– Diagnosis code-Procedure code compatibility
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Area of Review
• Electrocardiograms
– Global
– Technical
– Professional
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Area of Review
• Units of service
– Documentation
– Chargemaster
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Area of Review
• Modifiers
– Hard Coded
– Soft Coded
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Case Study 1
Patient presents to the hospital outpatient clinic for
anti-neoplastic chemotherapy. IV injections of
Benadryl and Zofran are given as premeds.
Chemotherapy infusion via port is then administered
over 3 hours.
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Case Study 1
Patient presents to the hospital outpatient clinic for anti-neoplastic chemotherapy. IV injections of
Benadryl and Zofran are given as premeds. Chemotherapy infusion via port is then
administered over 3 hours.
96413: First hour of Chemotherapy administration, IV infusion
96415 x 2: Second and third hour of chemotherapy administration, IV infusion;
each addtl. Hour
96375 x 2: Two therapeutic/prophylactic or diagnostic injection; each addtl
sequential IV push of new substance/drug
*Do not report 96374. See hierarchy
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Case Study 2
In the last several months the patient has had a 1 cm flesh-colored nodule on the face with no
surface change. Patient also has a couple of actinic keratoses on the ears that I froze today. I did a
limited skin check of the scalp, face, neck, and hands.
After we did time-out and the patient gave permission, I anesthetized the nodule with Xylocaine,
and took an elliptical biopsy. I sutured him with 2 sutures and will have the sutures taken out in 9
days.
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Case Study 2
In the last several months the patient has had a 1 cm flesh-colored nodule on the face with no
surface change. Patient also has a couple of actinic keratoses on the ears that I froze today. I
did a limited skin check of the scalp, face, neck, and hands.
After we did time-out and the patient gave permission, I anesthetized the nodule with Xylocaine,
and took an elliptical biopsy. I sutured him with 2 sutures and will have the sutures taken out in 9
days.
17000: Destruction of first AK
17003: Destruction of second AK
11100-59: Separately identifiable biopsy
* Modifier -59 is necessary to reflect that the biopsy procedure was not a part of the
destruction
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Case Study 3
A #22-French rigid cystoscope was advanced per urethra into the patient's bladder. A
survey with a 30-degree lens disclosed no abnormalities of the bladder or urethra.
The polaris stent was immediately visible. A 2 prong grasper was used to retrieve the
stent. This was pulled to the urethral meatus, a bentson wire was passed through the
stent to the renal pelvis. The stent was then removed.
Chargemaster assigned code: 52332 (Cystourethroscopy with insertion of indwelling
ureteral stent (e.g. Gibbons or double-J type)
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Case Study 3
A #22-French rigid cystoscope was advanced per urethra into the patient's
bladder. A survey with a 30-degree lens disclosed no abnormalities of the bladder or
urethra. The polaris stent was immediately visible. A 2 prong grasper was used
to retrieve the stent. This was pulled to the urethral meatus, a bentson wire was
passed through the stent to the renal pelvis. The stent was then removed.
1. Stent removal documented, Not stent insertion
2. 52310 (Cystourethroscopy with removal of foreign body, or ureteral stent from
urethra or bladder; simple)
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Case Study 4
A 35 y.o. male unrestrained passenger was involved in a MVC. Patient was transported to the ED
with multiple injuries. An intermediate repair of the 2.5 cm right forearm laceration was
documented. The patient complains of chest pain and headache. The nuclear medicine
department performs an EKG. The patient is then taken to xray where a frontal view chest xray
and Head CT without contrast are done.
Chargemaster assigned codes:
12001: 2.5cm simple laceration repair of forearm
93000: global EKG
71010: frontal view Chest xray
70450: Head CT without contrast
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Case Study 4
A 35 y.o. male unrestrained passenger was involved in a MVC. Patient was transported to the ED
with multiple injuries. An intermediate repair of the 2.5 cm right forearm laceration was
documented. The patient complains of chest pain and headache. The nuclear medicine
department performs an EKG. The patient is then taken to xray where a 2-view chest xray and
Head CT without contrast are done.
Correct codes:
12031: 2.5cm intermediate laceration repair of forearm
93005: EKG, technical component only
71010: Chest xray
70450: Head CT without contrast
*For Medicare and other carriers following NCCI, append modifier -59 to 93005
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Case Study 4
1. EKG code for facility reporting would be for technical service only
(93005)
2. Edit received for EKG on same calendar date as the laceration repair?
– Is a Modifier supported?
– If so, which one?
– Which code should it be appended to, if appropriate?
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Ensuring Accuracy
• Create a chargemaster Team
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Ensuring Accuracy
• Contractual Obligations
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Ensuring Accuracy
• Billing descriptions
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Ensuring Accuracy
• Revenue Cycle Training
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Ensuring Accuracy
• Charge Description Master Review
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Ensuring Accuracy
• Medical Necessity
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Ensuring Accuracy
• Electronic Medical Records
– Hybrid records
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Ensuring Accuracy
• Electronic Medical Records
– Templates
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Ensuring Accuracy
• Education is the key
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Thank You!
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