DYNAMIC CHARGEMASTER STRATEGIES AND EMERGING TRENDS. Glenda J Schuler, RHIT, CPC, COC Vice President, Revenue Cycle Solutions

Transcription

1 DYNAMIC CHARGEMASTER STRATEGIES AND EMERGING TRENDS Glenda J Schuler, RHIT, CPC, COC Vice President, Revenue Cycle Solutions

2 Disclaimer 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. 2

3 Chargemaster & Reimbursement Strategies Data Mining what internal reports are key Chargemaster automated charge capture processes Chargemaster Maintenance and Updates Tools to Stop Revenue Loss 3

4 Financial Forecasts If hospitals improve financially, it will most likely be due to improved operations rather than increased investment returns. Fitch IBCA, Duff & Phelps 4

5 Charge Description Master- What Is It? What is a charge description master (CDM)? Menu of all services and supplies/implants/pharmaceuticals provided by the facility, usually listed by department 5

6 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description Price CPT/HCPCS code Revenue code Multiplier, Unit of Service, Can also reside in the CDM 6

7 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description 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 13

8 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description 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) 8

9 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description 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 9

10 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description 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 10

11 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description 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 11

12 Pricing Strategies 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 12

13 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 13

14 Patient Friendly Descriptions 14

15 Gross Revenue Analysis of Charge Structure Mcare Reimb 15

16 Pricing Strategies - Supplies Sample of mark-up formula used for medical/surgical supplies: Cost Tiers Supplies Mark-up Average Supplies Markup Range < $ to $ $ to $ $ to $ $ to $ $ to $ $ to $ $1, > $1, to 9.73 Sample Size (Hospitals) 261 Implantables are often marked up costs x 4 16

17 Pricing Strategies - Procedures 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 Methodology #1 Methodology #2 17

18 Pricing Strategies - Procedures Set charges at 50 th - 75 th percentile of facilities in geographic area Purchase MedPar Data Obtain commercial claim data Strategic Price Analysis Does include selected facility pricing data Includes commercial payer contract considerations Sometimes across-theboard price increases not best return, selective procedure prices can increase or decrease Methodology #3 Methodology #4 18

19 Pricing Strategies - Pharmacy 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 19

20 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description 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 20

21 Common Information In The Chargemaster Department # Item # Internal description Patient-friendly description 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 21

22 Revenue Codes Not Requiring a CPT/HCPCS Code for Billing 025X Pharmacy 027X Medical supplies/devices Revenue Code 0278, Implantables do require HCPCS by some commercial payers 037X Anesthesia 0390 Blood storage/processing 071X Recovery room 0762 Observation 0942 Education & training services 22

23 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 23

24 UB-04 Claim Form Chargemaster data reported in this section of the claim form 24

25 FL #42, Revenue Code

26 Revenue Codes Requiring HCPCS (Partial List) 26

27 FL 43 Description 0324 Radiology Chest X-ray 27

28 Form Locator 43 Description The hospital s description of the service provided Usually reflects the revenue code description: Pharmacy Supplies X-ray CT scan Emergency room 28

29 FL 44 HCPCS/Rates 0324 Radiology Chest X-ray

30 FL 44 HCPCS 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 30.

31 FL 45 Service Date 0324 Radiology Chest X-ray

32 FL 45 Service Date 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 32

33 FL 46 Service Units 0324 Radiology Chest X-ray

34 FL 46 Service Units The number of times the service was provided. Service codes typically are a 1 one ER visit, one Chest X-ray 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 34

35 FL 46 Service Units 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 $ Revenue Code

36 FL 47 Total Charges 0324 Radiology Chest X-ray

37 FL 47 Total Charges 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 37

38 FL 48 Noncovered Charges 0324 Radiology Chest X-ray Pharmacy-Self Admin A9270GY

39 FL 48 Noncovered Charges 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) 39

40 Who Maintains the Chargemaster-The Team Who maintains the CDM? Revenue Integrity Clinical assistance Coding contribution Close communication with clinical departments Audit to determine what was ordered, performed and billed is consistent Billing input Financial involvement Compliance support 40

41 Revenue Integrity-Managing the Chargemaster Workflow Initiate 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 41

42 Revenue Integrity-Managing the Chargemaster Workflow Initiate Audits 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 PFS Validates projected revenue for clinical areas Retains compliance for governmental billing 42

43 Revenue Integrity-Managing the Chargemaster Workflow Initiate Audits Interface Integrity Charge Capture Chargemaster Chargemaster Coding Coding Billing 43

44 Revenue Integrity-Managing the Chargemaster Workflow Initiate Audits Interface Integrity Education 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 44

45 Who Maintains the Chargemaster-The Team Who maintains the CDM? Revenue Integrity Clinical assistance Coding contribution Billing input Financial involvement Engage clinical department expertise to review specific chargemasters More minds are better than one Department s area of business Compliance support 45

46 Who Maintains the Chargemaster-The Team Who maintains the CDM? Revenue Integrity Clinical assistance Coding contribution Billing input Financial involvement Compliance support Determine what procedures should be hardcoded/soft-coded Assignment of modifiers Work NCCI edits Review MUE edits Assigns modifiers, e.g. modifier

47 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 ) CDM Num ber Billing Description G/L Key CPT R.C I&D SUBCUT ABSC SIMP I&D SUBCUT ABSC COMP I&D PILONIDAL ABSC MAJOR SURG LEVEL 1/1ST HR MAJOR SURG LEVEL 1 EA ADDL 15 MIN MAJOR SURG LEVEL II /1ST HR MAJOR SURG LEVEL II EA ADDL 15 MIN MAJOR SURG LEVEL III/1ST HR MAJOR SURG LEVEL III EA ADDL 15 MIN MINOR SURG CANCEL CASE

48 Chargemaster vs. HIM Coding 48

49 Manual Manipulation of UB-04 Claim Data Reimbursement... Screening and Diagnostic procedure on same claim form should generate CCI edits 49

50 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 50

51 Who Maintains the Chargemaster-The Team Who maintains the CDM? Revenue Integrity Clinical assistance Coding contribution Billing input Communication remains open for payer denials Revenue Code rejections Non-covered procedures Inpatient/Outpatient Financial involvement Compliance support 51

52 Who Maintains the Chargemaster-The Team Who maintains the CDM? Revenue Integrity Clinical assistance Coding contribution Contract Management communicates details Carve-out specific revenue codes Coverage policies Billing input Financial involvement Compliance support 52

53 Who Maintains the Chargemaster-The Team Who maintains the CDM? Revenue Integrity Clinical assistance Coding contribution Billing input Financial involvement Compliance support 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 53

54 Identified Revenue Opportunities Easily Recognized By Analyzing Revenue and Usage Data 54

55 Procedures with One-to-One Reporting CPT Motion fluoroscopic evaluation of swallowing function by cine or video recording Swallowing function, with cineradiography/ video-radiography Speech-Pathology Procedure Radiology Procedure 55

56 Speech Pathology Evaluation and Fluoroscopy IP Volume 2016 OP Volume 2016 Total 2016 Volume Default CPT/HCPCS Code SIM Code FIM Code SIM Description Primary Price ST VIDEO SWALLOW STUDY $ GN RA MODIFIED BARIUM SWALLOW $1, TOTAL 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 56

57 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, UHC 8% Charges 5% $ Self Pay 3% $3, Other 18% No Add'l Net Reimbursement TOTAL $5,

58 Respiratory Therapy-Arterial Collections CPT 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) 58

59 Respiratory Therapy-Arterial Collections Dept Chg # Description Charge IP Volume OP Volume Total Volume CPT Code Resp Ther THERAPIST ABG DRAW $ Lab VENOUS BLOOD GASES $ Lab BLOOD GAS POINT OF CARE $ Lab ARTERIAL BLOOD GASES $ 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

60 Respiratory Therapy-Arterial Collections Dept Chg # Description Charge IP Volume OP Volume Total Volume CPT Code Resp Ther THERAPIST ABG DRAW $ Lab VENOUS BLOOD GASES $ Lab BLOOD GAS POINT OF CARE $ Lab ARTERIAL BLOOD GASES $ TOTAL Missed Procedures 1062 Not all specimen collections are obtained via arterial puncture. Nursing/Respiratory Therapists may collect from an established arterial catheter, see CPT 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 60

61 Respiratory Therapy-Arterial Collections Dept Chg # Description Charge IP Volume OP Volume Total Volume CPT Code Resp Ther THERAPIST ABG DRAW $ Lab VENOUS BLOOD GASES $ Lab BLOOD GAS POINT OF CARE $ Lab ARTERIAL BLOOD GASES $ TOTAL Nursing Svs SPECIMEN COLL EXIST CATH $ MISSING PROCEDURES 542 To quantify gross revenue for the above missing specimen collections: Missing procedures 542 x Charge of $ = $73,170 61

62 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 62

63 Actual Chargemaster Audit Results 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: 63

64 E.R. Visits Emergency Room ,180 Bell Curve-Technical Component E.R , , , , Evaluation and Management Codes ,360 Total 501,724 64

65 Emergency Room: Inappropriate Bell Curve ER Volume 8,000 6,000 4,000 2, Series1 2,258 5,893 1,

66 Emergency Room: Projected Gross Revenue YTD OP Qty Avg Charge Additional Revenue Proj Var. Projected ,258-1, $75 -$112, ,893-4,000 1,893 $139 -$556, ,828 4,200 6,028 $209 $877, ,336 $345 $327, $378 $94, $807 $80,700 10, ,435 $712,250 66

67 Emergency Room-Critical Care Hospitals are required to use HCPCS code to report outpatient encounters in which critical care services are furnished. The hospital is required to use HCPCS code in place of, but not in addition to, a code for a medical visit or for an emergency department service. CPT Critical care, evaluation and management of the critically ill or critically injured patient; first minutes CPT 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) 67

68 Emergency Room-Hard Coded CPT Codes Charge Code Charge Description Rev Code Price HCPCS CODE 27810F CLSD TX BIMAL ANKL FX W MANIP 450 $ F CLSD TX TRIMAL ANKL FX WO MANIP 450 $ F CLSD TX TRIMAL ANKL FX W MANIP 450 $ F CLSD TX PROX TBF DSLC WO ANESTH 450 $ F CLSD TX PROX TBF DSLC W ANESTH 450 $1, F CLSD TX ANKLE DISLOC WO ANESTH 450 $ F CONTROL OF NOSEBLEED 450 $ F REPEAT CONTROL OF NOSEBLEED 450 $ F INSERT EMERGENCY AIRWAY 450 $ F LARYNGOSCOPY;INDIRECT DX 450 $ F REMOVE FOREIGN BODY LARYNX 450 $ F LARYNGOSCOPY;FLEX F/O DX 450 $

69 Emergency Room-HIM Assigned CPT Codes Charge Code Charge Description Rev Code Price ER PROC ORTHO LEVEL $ ER PROC ORTHO LEVEL $ ER PROC ORTHO LEVEL $ ER PROC INTEGUMENTARY LEVEL $ ER PROC INTEGUMENTARY LEVEL $ ER PROC INTEGUMENTARY LEVEL $ ER PROC OCCULAR LEVEL $ ER PROC OCCULAR LEVEL $ ER PROC OCCULAR LEVEL $ ER PROC DIGESTIVE LEVEL $ ER PROC DIGESTIVE LEVEL $ ER PROC DIGESTIVE LEVEL $ HCPCS CODE 69

70 Emergency Room-Procedure Charge Methodologies 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 Chargemaster-Hard Coded 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 HIM-Assigned CPT Codes 70

71 Clinic Encounters Commercial vs Medicare OP Description Volume Clinic Visit Level 1 New/Est Clinic Visit Level 2 New/Est 1320 Clinic Visit Level 3 New/Est 15 Clinic Visit Level 4 New/Est 0 Clinic Visit Level 5 New/Est 0 TOTAL 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 Commercial Payers Incl Medicaid Medicare 71

72 Interventional Radiology 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

73 Interventional Radiology CPT Description Charge APC Shoulder arthrography $ Injection Shoulder arthrog $237 Status "N" Missed Procedures Status "N" Missed Gross Revenue $8,769 $3,555 $5,925 $18,249 Status "N" CPT Description Charge APC Knee arthrography $ Inj knee arthrography $200 Status "N" Missed Procedures 14 Status "N" Missed Gross Revenue $0 $2,800 $2,800 Status "N" CPT Description Charge APC Hip arthrography $ Inj hip arthrography $202 Status "N" Missed Procedures Status "N" Missed Gross Revenue $6,262 $5,050 $11,312 Status "N" Three Years Gross Revenue Opportunity $32,361 73

74 Interventional Radiology CPT Description Charge APC Urethrocystography voiding $ Cystogram min 3 views $ Inj urethro voiding $241 Status "N" Missed Procedures Status "N" Missed Revenue $31,571 $6,989 $20,967 $59,527 Status "N" CPT Description Charge APC Urethrocysto retrograde $ Inj Urethrocysto retro $200 Status "N" Missed Procedures Status "N" Missed Revenue $5,600 $5,000 $5,200 $15,800 Status "N" 74

75 Blood Administration, OCE Edit Billing Issues 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 75

76 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 76

77 Blood Administration Analysis Chg # Charge Description Charge IP Utilization OP Utilization Total Util CPT Code PLT PHER LR QUAD IRR $1, P CRYOPRECIPITATE 5 UNIT POOL $ P LRPC $ P PLATELETS PHERESIS LEUKORED REDU$1, P PLATELETS PHERESIS LEUKOCYTES RE $1, P LRPC QUAD IRRAD $ P LRPC IRRAD $ P FRESH FROZEN PLASMA $ P9059 TOTAL 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 77

78 Blood Administration Analysis Chg # Charge Description Charge IP Utilization OP Utilization Total Util CPT Code NB BLOOD ADMINISTRATION $1, BLOOD ADMINISTRATION $1, BLOOD ADMINISTRATION $1, BLOOD ADMINISTRATION $1, TOTAL It appears the facility missed 1,727 administration charges for inpatients and 276 charges for outpatient encounters 78

79 Blood Administration Analysis Charge Description IP Utilization OP Utilization Total Util Reported Blood Products Two products per administration Reportable Transfusion Procedure Reported Transfusion Services Missed Transfusion Procedures Charge for Transfusion Procedure $1,200 $1,200 $1,200 Gross Revenue Opportunity $2,073,000 $331,800 $2,404,800 79

80 Charge Capture Processes and Use of Technology As A Helpful Tool 80

81 Charge Capture Processes 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 81

82 Charge Panels, Explodes or Links 82

83 Manual versus Automated Processes 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 samplebased chart auditing techniques Can help reduce charging errors over time 83

84 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 84

85 Recommended Resources Tools of the Trade 85

86 8 6 Internet Resources 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

87 Medicare s Main Website 87

88 Additional Resources 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 88

89 Structure of the Chargemaster 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 89

90 Median Payer Mix Self Pay and Others Managed Care Blue Cross/Commercial Medicaid 13% 9% 45% Medicare 26% 7% 90

91 Chargemaster Accommodating Additional Payer Requirements SER VIC E R EV R EV 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 B A LLOON D IA LA T ION C A T H ET ER S C 1726 Y7107 R EV M C A ID B ILIA R Y ST ON E R EM OVA L B Y T T UB E 1, B IR D S N EST F ILT ER 1, C 1880 Y B ON E B X SUP ER F IC IA L B X LUN G/ M ED IA ST IN UM EXC H A N GE GUID EWIR E C 1769 Y F EM OR A L R UN OF F (UN I) F EM OR A L R UN OF F A R T ER IO (B I) 1, M R A A B D OM EN M R A A B D OM EN WO C ON T 1, C M R A C H EST M R A C H EST WO C ON T 1, C M R I C H EST M R I C H EST WO C ON T 1, C M R A A B D OM EN W&W/ O C ON T 1, C M R A A B D OM EN W/ C ON T 1, C

92 Final Thoughts Mastering change is key element for success 2017 offers new challenges Good luck!!! 92

93 Biography: 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 93

94 HealthCare Consulting Solutions 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 94

95 For Additional Information: HealthCare Consulting Solutions For additional information on our consulting and education/training solutions, please contact: Jeff Neustaedter, President HCS HealthCare Consulting Solutions Cell 95