Chargemaster 101: Key Elements in the Chargemaster

Transcription

1 Chargemaster 101: Key Elements in the Chargemaster Presented by Sandy Sage RN, HomeTown Health, LLC October 12, 2017 A PORTION OF THESE MATERIALS WERE PRODUCED PURSUANT TO THE Iowa Small Hospital Improvement Program (SHIP) Grant FY 17, IA Contract #5888SH01 and the Georgia Small Hospital Improvement Grant FY 17 Hospital Transformation Consortium WEBINAR ETIQUETTE All attendees are in Listen Only mode Questions or comments? - Open Questions pane in dashboard. - Type in comments or questions. - Comments will be monitored throughout webinar. - Questions will be addressed at end of the webinar. 1

2 Hospital Transformation Consortium WEBINAR RESOURCES This webinar will be recorded and ed to you to share with others on your team. Handouts are available for download in the Handouts pane and will be ed out to attendees after the webinar. Hospital Transformation Consortium GROUP PARTICIPATION Are you on this webinar with a group? If so, please enter: first/last names and addresses of those in attendance with you in the Questions Pane. 2

3 AGENDA Welcome & Introductions Chargemaster 101: Key Elements Upcoming Events & Resources Desi Barrett, HomeTown Health, LLC Sandy Sage RN, HomeTown Health, LLC Sandy Sage HomeTown Health, LLC Last Month s To Do List Determine who at your facility is responsible for maintaining your Chargemaster. Download your Chargemaster into an excel spreadsheet. Include: Item code Revenue code Description Department CPT/HCPCS code and any modifiers Charge amounts 3

4 Poll Question Prior To Do List Each department manager should have been provided with a copy of their department s Chargemaster Each manager should have looked over and become familiar with their department s Chargemaster All department managers should be on this webinar! 4

5 Poll Question Learning Outcomes List the key elements in a Chargemaster Describe the purpose of a revenue code Identify how CPT codes are used List commonly used modifiers and their purpose Identify the two ways a CPT code may end up on a claim 5

6 What is a Chargemaster? It is the foundation of the hospital Revenue Cycle 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. What is a Chargemaster? 6

7 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 7

8 Key Data Elements Charge code or item number (mnemonic) Description GL number Department Price/Charge HCPCS/CPT code Revenue code Sample 8

9 Charge or item codes are hospital specific and are not part of the actual billing process. Charge/Item Codes They are used to identify items in the charging process for the hospital staff. Usually department specific. Descriptions Long and Short Descriptions Long details the procedure or supply Short for order entry system Example: MRI Abdomen Without Contrast MRI Abd w/o System specific for # of characters The long description is patient friendly 9

10 GL Codes GL General Ledger Allows charges to be mapped to the correct financial ledger for cost reporting. Allows your CFO to track revenue and cost Check with the CFO for more information specific to your hospital Department Codes Identify the department the service was performed in Gives credit to the department for services or supplies Allows departments to manage their budgets Can be used in cost reporting 10

11 Revenue Codes 4 digit number, Zero is in front 0XXX What is a revenue code? 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. 11

12 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. 11X Private room* Revenue Codes Room and Board 12X Semi Private room* 13X Semi Private > 2 beds* 14X Private Deluxe* 15X Ward Room* 16X Other room and board 17X Nursery 19X Subacute care 20X Intensive Care 21X Coronary Care X=1 Medical/Surgical/Gyn X=2 OB X=3 Pediatric X=4 Psychiatric X=5 Hospice X=6 Detoxification X=7 Oncology X=8 Rehabilitation X=9 - Other 12

13 Revenue Codes Supplies Drugs 270 General supplies 250 General drugs 271 Non-sterile supplies 254 Drugs incidental to Dx proc. 272 Sterile supplies 255 Drugs incidental to Radiology 273 Take home supplies 256 Experimental drugs 274 Prosthetic/Orthotic devices* 275 Pacemaker* 258 IV solutions 276 Intra-ocular lens* 259 Other Pharmacy 277 Take home Oxygen 634 Erythropoietin < 10,000 units 278 Implants* 635 Erythropoietin > 10,000 units 279 Other supplies/devices 636 Drugs with detail coding *may need CPT/HCPCS 637 Self-administered drugs Revenue Codes Laboratory Blood 300 General 301 Chemistry 302 Immunology 304 Non-routine dialysis 305 Hematology 306 Bacteriology & Microbiology 307 Urology 311 Cytology 312 Histology 381 Packed Red Blood Cells 382 Whole blood 383 Plasma 384 Platelets 385 Leucocytes 386 Other components 390 General blood storage 391 Blood Administration Biopsy 13

14 Revenue Codes Radiology 320 General 321 Angiocardiography 322 Arthrography 323 Arteriography 324 Chest X-ray 350 General CT scan 351 Head CT scan 352 Body CT scan 359 Other CT scan 340 General Nuclear Medicine 341 Diagnostic NM 342 Therapeutic NM 343 Diagnostic Radiopharm. 344 Therapeutic Radiopharm. 610 General MRI 611 Brain MRI 612 Spinal Cord MRI 619 Other MRI Revenue Codes IV Therapy 260 General 261 Infusion Pump 262 IV Therapy Pharmacy service 264 IV Therapy supplies GI Services 750 General 759 Other GI services Operating Room 360 General 361 Minor Surgery 362 Organ Transplant 367 Kidney Transplant Anesthesia 370 General 371 Incident to radiology 372 Incident to other services Acupuncture 14

15 Revenue Codes Other Imaging 401 Diagnostic Mammography 402 Ultrasound 403 Screening Mammography 404 PET scans 409 Other imaging services Respiratory 410 General 412 Inhalation services 413 HBO 419 Other Respiratory services 460 Pulmonary Function 730 EKG 731 Holter Monitor 732 Telemetry Other Revenue Codes Therapy 420 Physical Therapy 430 Occupational Therapy 440 Speech Therapy XX1 Visit XX2 Hourly XX3 Group rate XX4 Evaluation or Reevaluation XX9 - Other Other 330 Chemotherapy Anesthesia 450 Emergency Room 480 Cardiology 510 Clinic 610 MRI 710 Recovery Room 720 Labor and Delivery 761 Outpatient Treatment Observation 15

16 Other Revenue Codes Other Pro Fees 740 EEG 771 Vaccine Administration 780 Telemedicine 800 Inpatient Dialysis 900 Behavioral Health 921 Peripheral vascular lab 990 Patient Convenience Items Anesthesia MD 964 Anesthesia CRNA Radiology 981 ER 982 Outpatient Department 983 Clinic 987 Hospital Visit CPT Codes 16

17 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 Codebook Sold by the American Medical Association Contains rules and guidelines related to the codes CPT Professional Includes CPT codes, Modifiers, Summary of additions, deletions and revisions, and more in the addendums HIM, Lab, Radiology, OR and Billing departments should all have a copy of the CPT codebook!! Chargemaster updates will need to come from departments that understand CPT codes 17

18 CPT Codebook It is important to note that CPT codes are updated January 1 st of every year. Some payers may give a grace period but some will not. Have your charges updated and the new codes ready to go on the 1 st of the year. What is a CPT code? CPT codes describe supplies or procedures, they are NOT diagnosis codes. A CPT code is considered by CMS to be Level I codes. CPT codes are 5 numerical digits Separated into 6 sections: Evaluation and Management Anesthesiology Surgery Radiology Pathology and Laboratory Medicine

19 What is a CPT code? CPT codes determine provider reimbursement for outpatient claims (OPPS) (EDITS) When CPT codes are billed with ICD-10 diagnosis codes they describe why the patient was seen and what services were provided In outpatient coding using a CPT code without an ICD-10 code will result in no reimbursement Inpatient claims do not require reporting of CPT codes CPT Code Examples When can a CPT code be used more than once in your Chargemaster? When services are done in more than one area. IV Injection IM Injection Foley Catheter Insertion These 3 procedures can be done in multiple departments including ER, OP, Observation, OR, etc. All of these areas have different revenue codes. 19

20 Multiple Departments When 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. Best practice is to charge the same price for CPT codes that are in the Chargemaster multiple times. Don t charge $75 for an injection in the ER and $150 for the same injection in another outpatient department. CPT Book Descriptions Descriptions may include wording like: physician, qualified healthcare professional, or individual. This does NOT mean that hospitals cannot report those codes. Some code descriptions DO limit where the procedure can be performed like: Home Health, Hospital or Office.* Some codes have notations that they cannot be billed with other specified codes. 20

21 Component Codes Also known as Comprehensive codes. A 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 X-ray of foot complete X-ray of toes (included in the 73630) Cannot 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 21

22 HCPCS CODES Level II codes Primarily used to identify products, procedures and supplies that are not included in the CPT Level I codes. Ambulance, DME, implants, drugs, supplies, etc. Maintained by CMS, updated quarterly A temporary HCPCS code may be assigned if it is not time for the new code updates. Codes will be replaced by permanent codes and cross walked to new codes HCPCS CODES HCPCS codes are alpha-numeric, 5 digit codes. The first digit is the alphabetic digit and usually signifies the type of item being described. Medicare may require you to continue to use a HCPCS code when other payers are requiring a comparable CPT code Both codes must be put in the Chargemaster for billing. Your financial system will be programmed to use the correct code depending on the payer being billed. 22

23 HCPCS CODES Example of a service where you will use both a HCPCS code and a CPT code: Mammogram and G0202 Screening mammography, bilateral, including (CAD) and G0204 Diagnostic mammography, including (CAD) when performed; bilateral and G0206 Diagnostic mammography, including (CAD) when performed; unilateral. CMS is using the G codes because their systems are not ready to process the CPT codes Modifiers 23

24 2-digit code used to communicate more detailed information related to a service or procedure. What is a Modifier? 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. 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 What is a Modifier? 24

25 2 Types of Modifiers Pricing Modifiers Informational Modifiers Affect the payment Should always be in the first field Provides additional information Use after the pricing modifier When to use a Modifier? When payment may be increased or decreased To identify if it s a technical or professional service To identify repeated services To identify an increased, reduced or unusual service To identify a specific body area To designate unilateral or bilateral procedures Other 25

26 Commonly Used Modifiers Modifiers that may be in the Chargemaster: 91 Repeat Laboratory Test 76 Repeat Test or Procedure (not lab) LT Left side (of body) RT Right side (of body) 50 Bilateral procedure (both sides) QW Laboratory Waived Test Commonly Used Modifiers Therapy Modifiers that may be in the Chargemaster: GP Outpatient physical therapy GO Outpatient occupational therapy GN - Outpatient speech therapy 26

27 Commonly Used Modifiers Modifiers that should NOT be in the Chargemaster: 59 Distinct procedure or service 52 Reduced service 53 Discontinued service 73 Discontinued surgery prior to anesthesia 74 Discontinued surgery after anesthesia These affect reimbursement! Modifiers not in CDM JW Drug amount discarded, not administered GA or GX An ABN was given GY or GZ An ABN was not given E1 or E2 Eyelids FA to F4 Finger modifiers TA to T4 Toe modifiers 27

28 Other Modifiers Anesthesia Modifiers can affect your reimbursement AA Services performed by Anesthesiologist QX CRNA service with medical direction QZ CRNA service without medical direction Medical direction- when a physician directs the CRNA the type and amount of anesthesia to be given. Does not mean that a surgeon is in the room If you use QX, reimbursement is cut 50% 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. 28

29 Other Modifiers Modifier TC is to identify the Technical Component of a test, usually Radiology. It is generally assumed that if an exam is billed on a hospital claim (UB04) that it is the technical component. Some payers will deny CPT codes with TC attached. Modifier Don ts Do not use a modifier to bypass claim edits Do not use modifiers on a claim that contradict each other, Example: You should not use an LT modifier and a 50 modifier on the same code (left and bilateral contradict) Left kidney removal and bilateral kidney removal would not work together 29

30 Modifier Don ts Do not bill a LT and an RT on the same date of service 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. Who Assigns the Codes? 30

31 CPT/HCPCS CODES Charge Master assigned codes Lab, Radiology, ER Levels, Nursing Procedures, Pharmacy Examples: Injections, Infusions, All x-rays, All Lab, other nursing procedures Codes flow from the Chargemaster to the bill Modifiers may be applied after charging by HIM CPT/HCPCS CODES HIM assigned codes Surgical/ER procedures Examples: Major surgeries done in OR, suture procedures in the ER Every procedure that is coded by HIM, with a CPT code, MUST have a charge from your Chargemaster associated with it! 31

32 REVIEW 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. CPT and HCPCS codes, where to find them, how to use them and who applies them. Modifiers, how, when and why to use them. Charging for services, where the charge goes and how it gets there. 32

33 Learning Outcomes List the key elements in a Chargemaster Describe the purpose of a revenue code Identify how CPT codes are used List commonly used modifiers and their purpose Identify the two ways a CPT code may end up on a claim But we aren t done today. Let s Get Started!! 33

34 Treatment/Observation OP Treatment Room Revenue Code 761 Treatment Room CPT Code or Simple Assessment Procedure without CPT code ONLY charge the treatment room if you are doing a procedure without a CPT code! Payers will NOT pay both unless a completely separate Evaluation and Management has been done! Procedures without a CPT could include enemas, dressing changes, blood pressure checks etc. 34

35 OP Procedures Dept RC Description CPT code Price OP 761 Foley Catheter Insertion $ OP 761 Change G tube $ OP 761 Gastric Intubation/Lavage $ OP 761 PICC line Insertion $ OP 300 In and Out Specimen Collection P9612 $ OP 300 FSBS $ Any OP procedure done in a treatment room or at the bedside of an Observation patient should be charged and billed with revenue code 761. OP Treatment Room Charge Injections and Infusions using either revenue code 761 for site of service (OP) or 260 for IV therapy. If a patient comes in with an order for an injection or infusion, DO NOT charge for the treatment room. Remember: Injections and infusions will be charged in multiple departments, be consistent with pricing. 35

36 Observation Revenue Code 762 If a patient is admitted to Observation from an outside source i.e. doesn t come through ER or SDS, you must add a charge for Direct Admit. G0379 Direct Admit to Observation G0378 or Observation per hour Always bill injections and infusions RC 761 or 260 Nursing Managers Sit down Go Check Confirm Sit down with your copy of the CDM, the HCPCS code book and the AMA CPT code book. Go through the charges in revenue codes 761 and 762 Check to make sure everything you do for outpatients is listed in the correct revenue code Confirm that you have a charge for Direct Admit to Observation G

37 Nursing Managers Identify Remove Add Check Identify any codes that are in your CDM that are no longer active (Not in the code book) Remove or delete any inactive codes Add any missing procedures with the correct revenue code (761) Check to make sure you have a process in place for correct charging Respiratory Therapy 37

38 Respiratory Therapy (RT) There has been new CMS guidance for Respiratory services issued in Respiratory service charges are being more and more restricted in the outpatient hospital setting. It is important for all RT staff to know what can and can t be charged and the frequency allowed. This is a department that is subject to audit for overcharging units of service based on the numbers allowed by the Medically Unlikely edits. Respiratory Revenue Codes RC Description 410 General Respiratory Service 412 Inhalation Services 413 Hyperbaric Oxygen Therapy 419 Other Respiratory Services 460 General Pulmonary Function 469 Other Pulmonary Function 730 General EKG 731 Holter Monitor 732 Telemetry 739 Other 740 EEG 38

39 Respiratory Respiratory CPT codes are found in the Medicine section of the CPT code book starting with CPT code If you are a hospital that does not keep ventilator inpatients you cannot bill CPT code if you initiate a ventilator in the ER for transfer, only the ER Level charge will be paid. Read the CPT code RT section carefully to familiarize yourself with the special rules for this department. Respiratory Rules Spirometry measures expiratory airflow but if you do spirometry before and after an inhalation treatment; should be charged. You would not charge the spirometry nor the inhalation treatment Measurement of Vital Capacity is only reported when it is the only test done pulmonary function tests are reported for infants through 2 years old only. There are many more rules that you will read related to what codes can and cannot be billed and reported together 39

40 94640 Inhalation Treatment Treatment of acute airway obstruction with inhaled medicine or to induce sputum for diagnostic testing. If these drugs are given back to back or continuously to exceed one hour, report with and not The inhaled medication can be charged and reported separately. Medicare will NOT pay for and or on the same date of service Inhalation Treatment 2017 CMS NCCI manual, Chapter 11, page 25 effective 1/1/17 If inhalation treatments are administered to patients as an outpatient service, including services administered in the Emergency Department, CPT code should only be reported once during an episode of care regardless of the number of separate inhalation treatments that are administered. An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility. If a patient receives inhalation treatment during an episode of care and returns to the facility for a second episode of outpatient care that also includes inhalation treatment on the same date of service, the inhalation treatment during the second episode of care may be reported with modifier 76 appended to CPT code

41 Respiratory Rules Teaching a patient to use an inhaler can only be charged once per day. Do not bill on the same day with Resp Tx unless it is done on a separate visit Pulse oximetry ONCE PER DAY I see this frequently as an error on claims!! Routine use of pulse oximetry is non-covered (ER) Respiratory Pulse Oximetry is covered for the following diagnoses Signs/Symptoms of acute respiratory dysfunction Chronic Lung Disease, severe Cardiopulmonary disease, of neuromuscular disease involving respiratory muscles Multiple traumas Monitor for potential adverse reactions to medication Do not charge when used for routine vital signs or standing orders on a swingbed unit or other sub-acute unit 41

42 Pulmonary Rehab G Pulmonary rehabilitation, including aerobic exercise (includes monitoring), per session, per day Georgia Medicaid does NOT cover this HCPCS code. Most Medicare contractors have a policy regarding using this code so check your local LCDs. Other G codes that you may need in your CDM are: G0237, G0238 and G0239 Respiratory Managers Sit down Start Check Confirm Sit down with your copy of the CDM, the HCPCS book and the AMA CPT code book. Start at and go page by page to make sure that every exam you do is listed in your CDM. Check your revenue codes against the list in this webinar handout. Correct if needed. Confirm that your descriptions are correct and up to date 42

43 Respiratory Managers Identify Remove Add Check Identify any codes that are in your CDM that are no longer active (Not in the code book) Remove or delete any inactive codes Add any HCPCS codes that are required for Medicare billing. Notify your BOM Check that your department assignments are correct Radiology December 14 th Webinar EKG/EEG Emergency Room Operating Room Therapy 43

44 To Do List Go through the departments discussed today and identify any missing or invalid codes and correct. Make sure that the departments we will be discussing on the next webinar are in the hands of those department managers for review. Send me any questions you have about today s webinar or the departments that will be discussed next time. CONSORTIUM SUPPORT: WEBSITE DASHBOARD IOWA GA/FL Contact us for password PROGRAM CALENDAR Cheat Sheet 44

45 Resources Monthly Newsletter Visit the Dashboard to be added to the mailing list! Upcoming Events Date Time Title Description October am EST CDI Role #3 Nurses and Scribes October am EST Payor Matrix MCO update and Payor Matrix October 27 1 pm EST HCAHPS Provider Engagement November 13 1 pm EST MIPS Clinical Practice Improvement November 17 1 pm EST RHC-CQI Introduction & Identifying Clinic Issues 45

46 Questions? Questions about these resources or Upcoming Events? Contact: Sandy Sage, Financial Program Lead or Jennie Price, SHIP Program Manager TELL US HOW WE DID! A survey will launch after this webinar closes: please take a moment to give us your feedback on the training, speaker, content, webinar format, and anything else you can share! If there s something we can help your hospital with, please let us know! 46

47 References Payment/PhysicianFeeSched/Downloads/FAQ-Mammography-Services-Coding- Direct-Digital-Imaging.pdf SLevelIICodingProcedures pdf 47