Chargemaster Compliance & Revenue Capture Scott Treida, MT (ASCP), CPC Director 317-713-7950 streida@blueandco.com
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
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
CERT Medicare 2016, Improper Payments The fiscal year (FY) 2016 Medicare FFS program improper payment rate is 11.00 percent, representing $41.08 billion in improper payments 4
Claims Payment Reviews 5
Claims Payment Reviews Visit website for complete listing: https://www.performantrac.com/issuesunderreview.aspx 6
Claims Payment Reviews 7
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
Claims Payment Reviews 9
Claims Payment Reviews 10
Local Coverage Determinations & Articles 11
Local Coverage Determinations & Articles 12
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
Local Coverage Determinations & Articles 14
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
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
National Correct Coding Initiative (NCCI) 17
National Correct Coding Initiative (NCCI) 18
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
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
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
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
Developing an Effective CDM Infrastructure Dept # Charge # Descriptor RC CPT Mod Charge I/P Usage 3170 4401559 Flowcytometry/ tc 1 marker 312 88184 $ 128.00 6 30 3170 4400588 Flowcytometry/tc add-on 312 88185 $ 29.00 6 30 3170 4400437 Flowcytometry/read 9-15 312 88189 $ 81.00 6 30 3170 4401401 Decalcify tissue 312 88311 $ 47.00 82 212 3170 4401427 Special stains group 1 312 88312 $ 89.00 61 120 3170 4400494 Special stains group 2 312 88313 $109.00 21 40 3170 4400387 Histochemical stain 312 88314 $119.00 3170 4400512 Intraop cyto path consult 1 312 88333 59 $124.00 3170 4400486 Immunohisto antibody stain 312 88342 $48.00 3 37 O/P Usage CPT codes and descriptions only are copyright American Medical Association. All Rights Reserved. 23
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
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
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
Charge Capture Compliance Tools Charge reconciliation Referral forms Benchmarking and analytics Development of job aides/charge sheets 27
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
1 2 7 7 26 28 29 30 34 36 Key CDM Hot Topics for 2017 National MCR O/P Avg. Ohio Statewide MCR O/P Avg. 99281 99282 99283 99284 99285 CMS Outpatient Standard Analytical File - Medicare - Calendar Year 2015 11 guiding principles, technical component: CMS 2008 OPPS Final Rule 29
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
Key CDM Hot Topics for 2017 31
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, 2016 32
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 413.65) 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
Key CDM Hot Topics for 2017 PBD Excepted* Offcampus Nonexcepted Modifier PO Modifier PN *Excepted: Dedicated emergency departments ( 489.24b) Items and services furnished in PBDs within 250 yards of a remote location of the hospital ( 413.65) 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
Key CDM Hot Topics for 2017 2017 OPPS Final Rule MLN Matters Number: MM9930 Off-Campus Provider Based Department PO Modifier Frequently Asked Questions 35
Questions 36
Scott Treida, MT (ASCP), CPC Scott Treida, MT (ASCP), CPC Director Blue & Co., LLC 500 N. Meridian St., Ste. 200 Indianapolis, IN 46204 317.713.7950 Streida@blueandco.com 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