Chargemaster Compliance & Revenue Capture. Scott Treida, MT (ASCP), CPC Director

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1 Chargemaster Compliance & Revenue Capture Scott Treida, MT (ASCP), CPC Director

2 Disclaimer This presentation has been designed to provide illustrative information with respect to the subject matter covered. The presentation itself, and views expressed within, do not establish standards or authoritative guidance within the practice area, nor do they represent the professional opinions or positions that the presenters would take in an actual assignment. The material was prepared by the presenters and has not been considered or acted upon by regulatory or technical committees within the industry and does not represent an official opinion of any such group or individual. It is provided with the understanding that the presenters have prepared such material for educational purposes and such presenters are not engaged in rendering any legal, accounting, or other professional service. Further, the views presented within this presentation are fact/circumstance sensitive, and are subject to different interpretation under various circumstances. If legal advice or other expert assistance is required, the services of a competent professional person should be sought. The presenters make no representations, warranties, or guarantees about, and assume no responsibility for, the content or application of the material contained herein and expressly disclaim all liability for any damages arising out of the use of, reference to, or reliance on such material. CPT is a registered trademark of the American Medical Association. 2

3 Claims Payment Reviews Recovery Audit Contractor (RAC) Comprehensive Error Rate Testing (CERT) Medicare Administrative Contractor (MAC) Office of Inspector General (OIG) Program Integrity Contractors (ZPIC) Several others 3

4 CERT Medicare 2016, Improper Payments The fiscal year (FY) 2016 Medicare FFS program improper payment rate is percent, representing $41.08 billion in improper payments 4

5 Claims Payment Reviews 5

6 Claims Payment Reviews Visit website for complete listing: 6

7 Claims Payment Reviews 7

8 Claims Payment Reviews The main factors that contribute to the claim payment error rate determination: Level of care billed not supported by documentation Undocumented service(s) Improperly or insufficiently documented service(s) Documentation is illegible, no date, improperly signed, etc. Missing orders Improper coding Documentation does not adhere to the specific policies outlined for specific diseases and procedures, where applicable. 8

9 Claims Payment Reviews 9

10 Claims Payment Reviews 10

11 Local Coverage Determinations & Articles 11

12 Local Coverage Determinations & Articles 12

13 Local Coverage Determinations & Articles Anatomy of an LCD Coverage indications, limitations, and/or medical necessity Coding guidelines ICD-10 codes that support medical necessity Documentation requirements Utilization guidelines Supplemental articles and instructions 13

14 Local Coverage Determinations & Articles 14

15 Outpatient Coding Resources CPT 2017 CPT Assistant Clinical Examples in Radiology Errata & Technical Corrections (ama-assn.org) HCPCS Level II Modifiers Medicare Claims Processing Manual National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) Local Coverage Determinations & Articles CGS Guides and Resources Center (website) Other 15

16 National Correct Coding Initiative (NCCI) The CMS developed the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payments. NCCI policies based on CPT coding conventions, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. Over 1 million PTP (procedure to procedure) edits Coding modifiers 16

17 National Correct Coding Initiative (NCCI) 17

18 National Correct Coding Initiative (NCCI) 18

19 Developing an Effective CDM Infrastructure CDM Committee New group, or extension of Revenue Cycle Team Executive sponsorship Make up: Finance/reimbursement CDM coordinator HIM Information systems Clinical leaders 19

20 Developing an Effective CDM Infrastructure CDM Committee Objectives Facilitate accurate billing in compliance with Medicare guidelines Improve consistency and accuracy of charge capture processes Reduce number of claims requiring manual intervention Identify opportunities for operational improvements (best practices) 20

21 Developing an Effective CDM Infrastructure CDM Committee Responsibilities Assess current processes and controls Optimize processes and formalize them into written policy Oversee CDM maintenance and implementation of new regulations Conduct on-going process improvement Monitor charge capture compliance Utilize external resources? 21

22 Developing an Effective CDM Infrastructure Chargemaster Without an accurate and up-to-date CDM, hospitals will not receive proper reimbursement for services rendered. Claim rejections, underpayments, overpayments, fines and penalties may result. CDM maintenance policy Clinical departments are responsible. Do not isolate them from the process. Annual review & quarterly updates Consider revenue usage statistics 22

23 Developing an Effective CDM Infrastructure Dept # Charge # Descriptor RC CPT Mod Charge I/P Usage Flowcytometry/ tc 1 marker $ Flowcytometry/tc add-on $ Flowcytometry/read $ Decalcify tissue $ Special stains group $ Special stains group $ Histochemical stain $ Intraop cyto path consult $ Immunohisto antibody stain $ O/P Usage CPT codes and descriptions only are copyright American Medical Association. All Rights Reserved. 23

24 Developing an Effective CDM Infrastructure Regulations Merely distributing regulations, coding/billing information to affected clinical areas RARELY achieves accurate and compliant reporting CDM end users are responsible Maintain key regulations (e.g., paper binder) Part A vs. Part B 24

25 Developing an Effective CDM Infrastructure Regulations Future updates CDM Committee to assess periodically Designated individual compiles updates Send to Committee prior to meeting Invite affected departments, as needed Discuss and implement controls Action plan 25

26 Charge Capture Compliance Tools Charge Capture Documentation Reviews Perform periodically Test new charges & updates to CDM Review compliance with coding and documentation requirements (CPT, NCCI, LCDs, etc.) Identify charge capture opportunity Verify payments received 26

27 Charge Capture Compliance Tools Charge reconciliation Referral forms Benchmarking and analytics Development of job aides/charge sheets 27

28 Key CDM Hot Topics for 2017 Resource Based Service Charges Operating Room levels / time Routine supplies Reusable equipment & instrumentation Staffing Room turn-over Etc. ER visit level distributions 28

29 Key CDM Hot Topics for 2017 National MCR O/P Avg. Ohio Statewide MCR O/P Avg CMS Outpatient Standard Analytical File - Medicare - Calendar Year guiding principles, technical component: CMS 2008 OPPS Final Rule 29

30 Key CDM Hot Topics for 2017 JW Modifier: Drug/Biological Amount Discarded/ Not Administered To Any Patient Effective January 1, 2017, modifier JW must be used in order to obtain payment for a discarded amount of drug in single dose or single use packaging under the Medicare discarded drug policy. Billing for wastage and/or using the JW modifier for drugs supplied in a multi-dose vial is prohibited. Providers must document the discarded drugs and biologicals in the patient's medical record. 30

31 Key CDM Hot Topics for

32 Key Coding Hot Topics for 2017 Resources: MLN Matters MM9603 Medicare Claims Processing Manual, chapter 17; sec. 40 Local Coverage Determination (LCD): Drugs and Biologics (Non-chemotherapy) (L34741) Frequently Asked Questions article; August 26,

33 Key CDM Hot Topics for 2017 Billing for Items and Services Furnished at Off-Campus Hospital Outpatient Departments OPPS Provider-based department (PBD) Off-campus (42 CFR ) Modifier PN : Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital. Modifier PO : Excepted services, procedures and/or surgeries provided at off-campus provider-based outpatient departments. 33

34 Key CDM Hot Topics for 2017 PBD Excepted* Offcampus Nonexcepted Modifier PO Modifier PN *Excepted: Dedicated emergency departments ( b) Items and services furnished in PBDs within 250 yards of a remote location of the hospital ( ) Off-campus PBDs that were furnishing services and billing Medicare under the OPPS prior to November 2, 2015 Relocation. Change of Ownership. Midyear build. 34

35 Key CDM Hot Topics for OPPS Final Rule MLN Matters Number: MM9930 Off-Campus Provider Based Department PO Modifier Frequently Asked Questions 35

36 Questions 36

37 Scott Treida, MT (ASCP), CPC Scott Treida, MT (ASCP), CPC Director Blue & Co., LLC 500 N. Meridian St., Ste. 200 Indianapolis, IN Mr. Treida is a Director on the Revenue Cycle Management Team with Blue & Co., LLC. Scott started consulting with Blue & Co. 20 years ago. He is responsible for coordinating and performing detailed work related to Blue s revenue cycle management services; concentrating on chargemaster (CDM) and coding quality reviews, regulatory compliance, and revenue cycle team development. Scott is a frequent presenter at local and national professional associations. Scott is a graduate of Indiana University with degrees in Biology and Medical Technology. He is a certified professional coder (CPC), and Medical Technologist with board certification by the American Society for Clinical Pathology (ASCP). 37