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Chargemaster 101
Learning Outcomeso List the key elements in a Chargemaster
oDescribe the purpose of a revenue code
o Identify how CPT codes are used
o List commonly used modifiers and their purpose
o Identify the two ways a CPT code may end up on a claim
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What is a Chargemaster?
It is the foundation of the
hospital
Revenue Cycle
What is a Chargemaster?
A Chargemaster is also called a Charge
Description Master or CDM
It is a master file built within the hospital information system.
It contains multiple data elements related to the charges that are assigned to items and services used or
provided for a patient.
Every item in the Chargemaster is assigned a set price used to generate bills.
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Why should it be maintained?1. It drives hospital reimbursement
2. It provides data for reporting
3. It ensures financial and governmental compliance
4. It provides information for your cost reporting
5. It helps create clean claims
6. It is the most important communication tool between providers and payers
What if it isn’t maintained?1. Decreases cash flow
2. You are unable to do accurate data gathering/reporting
3. It makes you vulnerable to audits and penalties
4. You are unable to accurately report your costs
5. Increase claims edits which creates a backlog and decreases cash flow
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Key Data Elements
Charge code or item number (mnemonic)
Description
GL number
Department
Price/Charge
HCPCS/CPT code
Revenue code
Sample
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Charge/Item Codes
Charge or item codes are hospital specific and are not part of the actual billing process.
They are used to identify items in the charging process for the hospital staff.
Usually department specific.
Descriptionso Long and Short Descriptions
o Long details the procedure or supply
o Short for order entry system
o Example: MRI Abdomen Without Contrast
MRI Abd w/o
o System specific for # of characters
o The long description is patient friendly
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GL Codes
oGL – General Ledger
oAllows charges to be mapped to the correct financial ledger for cost reporting.
oAllows your CFO to track revenue and cost
oCheck with the CFO for more information specific to your hospital
Department Codes
o Identify the department the service was performed in
oGives credit to the department for services or supplies
oAllows departments to manage their budgets
oCan be used in cost reporting
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Revenue Codes
What is a revenue code?
4 – digit number, Zero is in front 0XXX
Identify where the patient was when they received care or services or the type of supplies they received
Allows hospitals to use the same CPT code in multiple departments
Most revenue codes have sub-categories that better define where a service was performed or where care was provided.
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Revenue Codes
Revenue codes are an important
communication tool between providers and
insurers.
A charge on a UB-04 and on a CMS-1500 will
be rejected if it is missing a revenue
code.
Revenue CodesRoom and Board
o 11X – Private room*
o 12X – Semi Private room*
o 13X – Semi Private > 2 beds*
o 14X – Private Deluxe*
o 15X – Ward Room*
o 16X – Other room and board
o 17X – Nursery
o 19X – Subacute care
o 20X – Intensive Care
o 21X Coronary Care
X=1 – Medical/Surgical/Gyn
o X=2 – OB
o X=3 – Pediatric
o X=4 – Psychiatric
o X=5 – Hospice
o X=6 – Detoxification
o X=7 – Oncology
o X=8 – Rehabilitation
o X=9 - Other
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Revenue Codes
o 270 – General supplies
o 271 – Non-sterile supplies
o 272 – Sterile supplies
o 273 – Take home supplies
o 274 – Prosthetic/Orthotic devices*
o 275 – Pacemaker*
o 276 – Intra-ocular lens*
o 277 – Take home Oxygen
o 278 – Implants*
o 279 – Other supplies/devices
o 250 – General drugs
o 254 – Drugs incidental to Dx proc.
o 255 – Drugs incidental to Radiology
o 256 – Experimental drugs
o 258 – IV solutions
o 259 – Other Pharmacy
o 634 – Erythropoietin < 10,000 units
o 635 – Erythropoietin > 10,000 units
o 636 – Drugs with detail coding
o 637 – Self-administered drugs
oSupplies oDrugs
Revenue Codes
o 300 – General
o 301 – Chemistry
o 302 – Immunology
o 304 – Non-routine dialysis
o 305 – Hematology
o 306 – Bacteriology & Microbiology
o 307 – Urology
o 311 – Cytology
o 312 – Histology
o 314 - Biopsy
o 381 – Packed Red Blood Cells
o 382 – Whole blood
o 383 – Plasma
o 384 – Platelets
o 385 – Leucocytes
o 386 – Other components
o 390 – General blood storage
o 391 – Blood Administration
oLaboratory oBlood
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Revenue CodesRadiology
o 320 – General
o 321 – Angiocardiography
o 322 – Arthrography
o 323 – Arteriography
o 324 – Chest X-ray
o 350 – General CT scan
o 351 – Head CT scan
o 352 – Body CT scan
o 359 – Other CT scan
o 340 – General Nuclear Medicine
o 341 – Diagnostic NM
o 342 – Therapeutic NM
o 343 – Diagnostic Radiopharm.
o 344 – Therapeutic Radiopharm.
o 610 – General MRI
o 611 – Brain MRI
o 612 – Spinal Cord MRI
o 619 – Other MRI
Revenue CodesIV Therapyo 260 – General
o 261 – Infusion Pump
o 262 – IV Therapy Pharmacy service
o 264 – IV Therapy supplies
GI Services
o 750 – General
o 759 – Other GI services
Operating Roomo 360 –General
o 361 – Minor Surgery
o 362 – Organ Transplant
o 367 – Kidney Transplant
Anesthesia
o 370 – General
o 371 – Incident to radiology
o 372 – Incident to other services
o 374 - Acupuncture
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Revenue CodesOther Imaging
o 401 – Diagnostic Mammography
o 402 – Ultrasound
o 403 – Screening Mammography
o 404 – PET scans
o 409 – Other imaging services
Respiratory
o 410 – General
o 412 – Inhalation services
o 413 – HBO
o 419 – Other Respiratory services
o 460 – Pulmonary Function
o 730 – EKG
o 731 – Holter Monitor
o 732 – Telemetry
Other Revenue CodesTherapy
o 420 – Physical Therapy
o 430 – Occupational Therapy
o 440 – Speech Therapy
o XX1 – Visit
o XX2 – Hourly
o XX3 – Group rate
o XX4 – Evaluation or Re-evaluation
o XX9 - Other
Othero 330 – Chemotherapy
o 370 - Anesthesia
o 450 – Emergency Room
o 480 – Cardiology
o 510 – Clinic
o 610 – MRI
o 710 – Recovery Room
o 720 – Labor and Delivery
o 761 – Outpatient Treatment
o 762 - Observation
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Other Revenue CodesOther
o 740 – EEG
o 771 – Vaccine Administration
o 780 – Telemedicine
o 800 – Inpatient Dialysis
o 900 – Behavioral Health
o 921 – Peripheral vascular lab
o 990 – Patient Convenience Items
Pro Feeso 960-970-980
o 963 – Anesthesia – MD
o 964 – Anesthesia – CRNA
o 972-974 - Radiology
o 981 – ER
o 982 – Outpatient Department
o 983 – Clinic
o 987 – Hospital Visit
CPT Codes
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What is a CPT code?
Current Procedural Terminology is a code set licensed and maintained by the American Medical Association (AMA).
Each code describes a service or supply that can be provided.
The codes are designed and used to communicate information to the government and insurance providers.
Communicated codes are used for financial, administrative and analytic purposes.
Originally developed for physicians
CPT Codebooko Sold by the American Medical Association
o Contains rules and guidelines related to the codes
o CPT Professional
o Includes CPT codes, Modifiers, Summary of additions, deletions and revisions, and more in the addendums
o HIM, Lab, Radiology, OR and Billing departments should all have a copy of the CPT codebook!!
o Chargemaster updates will need to come from departments that understand CPT codes
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CPT Codebooko It is important to note that CPT codes are updated January 1st of every year.
o Some payers may give a grace period but some will not.
oHave your charges updated and the new codes ready to go on the 1st of the year.
What is a CPT code?oCPT codes describe supplies or procedures, they are NOT diagnosis codes.
oA CPT code is considered by CMS to be Level I codes.
oCPT codes are 5 numerical digits
o Separated into 6 sections:o Evaluation and Management 99201-99499
o Anesthesiology 00100-01999
o Surgery 10000-69990
o Radiology 70010-79999
o Pathology and Laboratory 80000-89399
o Medicine 90281-99199
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What is a CPT code?
oWhen CPT codes are billed with ICD-10 diagnosis codes they describe why the patient was seen and what services were provided
o In outpatient coding using a CPT code without an ICD-10 code will result in no reimbursement
o Inpatient claims do not require reporting of CPT codes
CPT Code ExamplesoWhen can a CPT code be used more than once in your Chargemaster? When services are done in more than one area.
o IV Injection 96374
o IM Injection 96372
o Foley Catheter Insertion 51702
These 3 procedures can be done in multiple departments including ER, OP, Observation, OR, etc. All of these areas have different revenue codes.
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Multiple DepartmentsoWhen a CPT code is in your Chargemaster in different departments the revenue code will communicate to the payer to let them know where the patient was when the procedure or service was provided.
oBest practice is to charge the same price for CPT codes that are in the Chargemaster multiple times.
oDon’t charge $75 for an injection in the ER and $150 for the same injection in another outpatient department.
CPT Book DescriptionsoDescriptions may include wording like: “physician”, “qualified healthcare professional”, or “individual”.
o This does NOT mean that hospitals cannot report those codes.
o Some code descriptions DO limit where the procedure can be performed like: “Home Health”, “Hospital” or “Office.*
o Some codes have notations that they cannot be billed with other specified codes.
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Component CodesoAlso known as Comprehensive codes.
oA component code may be a “lesser” code that only describes part of a more comprehensive procedure. When the comprehensive procedure is done the component code cannot be billed in addition to the comprehensive code.
o73630 – X-ray of foot complete
o73660 – X-ray of toes (included in the 73630)
oCannot bill together on same date of service without a modifier
"CPT copyright 2017 American Medical Association. All rights reserved.CPT is a registered trademark of the American Medical Association."
HCPCS Codes
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HCPCS CODESo Level II codes
oPrimarily used to identify products, procedures and supplies that are not included in the CPT Level I codes.
oAmbulance, DME, implants, drugs, supplies, etc.
oMaintained by CMS, updated quarterly
oA temporary HCPCS code may be assigned if it is not time for the new code updates.
oCodes will be replaced by permanent codes and cross walked to new codes
https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/Downloads/HCPCSLevelIICodingProcedures7-2011.pdf
HCPCS CODESoHCPCS codes are alpha-numeric, 5 digit codes.
oThe first digit is the alphabetic digit and usuallysignifies the type of item being described.
oMedicare may require you to continue to use a HCPCS code when other payers are requiring a comparable CPT code
oBoth codes must be put in the Chargemaster for billing.
oYour financial system will be programmed to use the correct code depending on the payer being billed.
https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/Downloads/HCPCSLevelIICodingProcedures7-2011.pdf
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Modifiers
What is a Modifier?
2-digit code used to communicate more detailed information related to a service or procedure.
Lends specificity to a CPT or HCPCS code without changing the meaning of the original code.
Modifiers can affect your reimbursement
Some modifiers can be “hard coded” in your Chargemaster, some are added by your coders.
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What is a Modifier?
You can find approved modifiers in the addenda in the back of the CPT
code book.
The book will give you the modifier
and the description for use.
Some codes may need more than one modifier applied.
Up to 4 per code are allowed
2 Types of Modifiers
•Affect the payment
• Should always be in the first field
Pricing Modifiers
• Provides additional information
• Use after the pricing modifier
Informational Modifiers
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When to use a Modifier?oWhen payment may be increased or decreased
o To identify if it’s a technical or professional service
o To identify repeated services
o To identify an increased, reduced or unusual service
o To identify a specific body area
o To designate unilateral or bilateral procedures
oOther
Commonly Used ModifiersModifiers that may be in the Chargemaster:
o91 – Repeat Laboratory Test
o76 – Repeat Test or Procedure (not lab)
o LT – Left side (of body)
oRT – Right side (of body)
o50 – Bilateral procedure (both sides)
oQW – Laboratory Waived Test
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Commonly Used Modifiers
Therapy Modifiers that may be in the Chargemaster:
o GP – Outpatient physical therapy
o GO – Outpatient occupational therapy
o GN - Outpatient speech therapy
Commonly Used ModifiersoModifiers that should NOT be in the Chargemaster:
o59 – Distinct procedure or service
o52 – Reduced service
o53 – Discontinued service
o73 – Discontinued surgery prior to anesthesia
o74 – Discontinued surgery after anesthesia
These affect reimbursement!
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Modifiers not in CDMo JW – Drug amount discarded, not administered
oGA or GX – An ABN was given
oGY or GZ – An ABN was not given
o E1 or E2 – Eyelids
o FA to F4 – Finger modifiers
o TA to T4 – Toe modifiers
Other ModifiersoAnesthesia Modifiers can affect your reimbursement
oAA – Services performed by Anesthesiologist
oQX – CRNA service with medical direction
oQZ – CRNA service without medical direction
oMedical direction- when a physician directs the CRNA the type and amount of anesthesia to be given.
oDoes not mean that a surgeon is in the room
o If you use QX, reimbursement is cut 50%
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More on QZ
When services are “personally performed” by an anesthesiologist (modifier AA) or a CRNA (Modifier QZ), there should not be a
second claim billed by another anesthesiologist or CRNA with a modifier indicating “medical direction of” an
Anesthesiologist for a procedure on same patient on the same day.
Practitioners may work under the same or different Tax IDs. In either scenario, it is the responsibility of
each practitioner to file correctly for
the services provided.
Other Modifiers
oModifier TC is to identify the Technical Component of a test, usually Radiology.
o It is generally assumed that if an exam is billed on a hospital claim (UB04) that it is the technical component.
o Some payers will deny CPT codes with TC attached.
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Modifier Don’ts
oDo not use a modifier to bypass claim edits
oDo not use modifiers on a claim that contradict each other, Example:
oYou should not use an LT modifier and a 50 modifier on the same code (left and bilateral contradict)
o Left kidney removal and bilateral kidney removal would not work together
Modifier Don’ts
o Do not bill a LT and an RT on the same date of service
o Example: 8 am you charge an x-ray of the right arm for a patient in the ER. At 10 am the doctor wants an x-ray of the left arm. Do not charge the LT and the RT, you must charge a bilateral exam.
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Who Assigns the Codes?
CPT/HCPCS CODESoCharge Master assigned codes
o Lab, Radiology, ER Levels, Nursing Procedures, Pharmacyo Examples: Injections, Infusions, All x-rays, All Lab, other nursing procedures
oCodes flow from the Chargemaster to the bill
oModifiers may be applied after charging by HIM
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CPT/HCPCS CODESoHIM assigned codes
oSurgical/ER procedures 10000-69999
oExamples: Major surgeries done in OR, suture procedures in the ER
oEvery procedure that is coded by HIM, with a CPT code, MUST have a charge from your Chargemaster associated with it!
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REVIEWo Everything you ever wanted to know about revenue codes and how they communicate to the payer location, type of service or supply and how it should be paid.
oCPT and HCPCS codes, where to find them, how to use them and who applies them.
oModifiers, how, when and why to use them.
oCharging for services, where the charge goes and how it gets there.
Learning OutcomesoList the key elements in a Chargemaster
oDescribe the purpose of a revenue code
o Identify how CPT codes are used
oList commonly used modifiers and their purpose
o Identify the two ways a CPT code may end up on a claim
