CATEGORY Compliance EFFECTIVE DATE November 3, 1999 REVISED October 31, 2002 INDEX PAGE 1 of 6 SYSTEM POLICY AND PROCEDURES SUBJECT: SCOPE: AUTHORIZATION: Baptist Healthcare System Service Item Master and Pathways Materials Management Database Maintenance Policy It is the responsibility of the Charge Management Coordinator (CMC), Pathways Materials Management Database Analyst (PMMDA), System Team Leaders (STLs), and Hospital Department Directors to assure that each hospital is in compliance with this policy. System Team Leaders have been identified for all areas that require SIM maintenance of CPT4 codes. Baptist Healthcare System, Inc. Carl Herde, Chief Financial Officer PURPOSE The purpose of this policy is to establish a process for Maintenance of the Service Item Master (SIM) and Pathways Materials Management Database (PMM) that supports standardization of item numbers for procedures, supply and Pharmacy items, and complies with Medicare regulations for billing. POLICY All BHS employees are responsible for ensuring that standardization is maintained and that items are added to the Service Item Master in a timely manner to ensure appropriate reimbursement as directed by Medicare regulations. PMM items must also be set up in accordance with established policies for commodity codes, expense codes, etc. SIM items must also be setup in accordance with established productivity, cost accounting and budgeting guidelines to maintain the integrity of the information used in these processes. All additions, changes, and deletions to the SIM screen, HCPC/CPT screen, and productivity flag screen will be made by the Corporate Compliance Department staff; the hospitals will continue to work with the screens for discounting, variable pricing, and yearly percentage price increases. All additions, changes, and deletions to the PMM database will be coordinated through the Corporate Compliance Department per established PMM policy. 1. DEFINITIONS: For the purpose of this policy, the following abbreviations shall have the meaning specified: DMA PMMDA CMC STL DSA SIM EDPFS CMO Database Management Assistant PMM Database Analyst Charge Management Coordinator System Team Leader Decision Support Analyst Service Item Master Executive Director of Patient Financial Services Care Manager Orders Coordinators 1
PMM BHS IS Pathways Materials Management System Baptist Healthcare System Information Services 2
PROCEDURES I. Maintenance of the Standardized Procedure SIM A. Requests for new procedures or modifications to the SIM should be submitted to Corporate Compliance utilizing the template. (see attached procedure) All information should be filled out on the template before sending to Compliance, including cost information, CPT code, patient charge amount, etc. SIM maintenance should be completed no later than seven (7) working days from the time the complete request was originally submitted (complete request is defined as all data elements are present and item has been defined by use). B. Requests for new procedures or changes to existing procedures that may affect productivity, budgeting or cost accounting should be discussed with the DSA or the Director of Finance at the individual facility prior to submission of a formal request. The Management Engineer should be consulted on productivity issues when necessary, per the Policy on Maintaining Premier Productivity Benchmarks. C. Requests for new procedures and any change to the SIM, such as description, HCPC or CPT code, must be approved by the STL on the template. The STL is not required to approve a price change or activation/deletion on an individual hospital s SIM. (See guidelines attached to this policy.) D. If the template is incomplete, it will be returned to the requestor for more information or clarification. If STL approval is required, the template should be sent to STL before submitting to Compliance. Upon approval, the STL will send to Compliance. Compliance will review all information and process the template. The BHS Master SIM and individual hospital SIM will not be modified until the applicable template is completed and reviewed. (see guidelines for SIM template attached to this policy) E. For additions and changes, the DMA will send an email notification to the appropriate SIM routes after the BHS Master and individual hospital SIM have been modified, (including CMO coordinators, the original requestor, and other appropriate individuals maintaining order entry systems). F. Templates containing deletions will be communicated to appropriate SIM routes (including CMO coordinators, the original requestor, and other appropriate individuals maintaining order entry systems) that the item needs to be removed. Once all necessary deletions are complete at the facility the information is communicated for the DMA to finalize deletion from the SIM. The DMA will send an email notification to the appropriate SIM routes once the BHS Master and individual hospital SIM have been modified. G. Staff supporting other applications (CMO, Sunquest, STAR Radiology, etc) will process the information as appropriate for the individual hospital within 3 business days. They will communicate with applicable departments and personnel that the SIM number is ready for use. H. It is the department director s responsibility to instruct staff and any other departments that will be using the new SIM number on its appropriate use, to educate users what changes were made and why, and how to appropriately use the affected SIM number. It is also the department director s responsibility to assure that all charge tickets are updated and revenue capture audits occur. I. The CMC and DMA will keep the documentation associated with the maintenance of the BHS SIM and the individual hospital SIM. This documentation must be maintained for a minimum of seven years. J. Because Medicare reimburses at the lower of fee schedule or charge, the department director and the CMC will review all items on the SIM on a biannual basis comparing patient charge to the Medicare diagnostic fee schedules for appropriateness. 3
K. If a CPT code is active, but not billable to Medicare, the CPT code will be added to the BHS Master SIM under claim indicator C. This will indicate that the CPT code is valid for payers other than Medicare. The CPT will be added to all applicable claim indicators for each facility. L. If the Business Office requires a CPT to be built on a claim indicator other than Medicare, it is the responsibility of the Business Office Director to notify the DMA or CMC of this need. These additions will be added to the individual hospital's SIM. II. Maintenance of the Standardized SIM and PMM Database for Supplies A. Requests for Supply additions, changes, and deletions are to be submitted via template by the department director or designee to the Materials Management Director or designee for approval. Once approved, the template is forwarded to Corporate Compliance. B. The DMA will review the template for needed action. If information is incomplete at any time during the review and/or processing of templates, the template will be returned to the requesting hospital for the required information. C. If the request is for a new supply item, the DMA will forward the template to the PMMDA for processing. The PMMDA will assign a PMM item number and set up the item in the PMM database. If the item is a chargeable item, the PMMDA will review the BHS Master SIM for an existing SIM number. If there is an existing SIM number that can be used, the PMMDA will add this information to the template. If there is no existing SIM number, the PMMDA will forward the template to the CMC for SIM assignment. D. After receiving the template from the PMMDA, the CMC will assign a SIM number, description, and HCPC code (if applicable and not provided by the hospital) and forward the template to DMA for addition to the Master SIM, the requesting hospital's SIM, and the PMM database. SIM maintenance should be completed no later than three (3) working days from the time the complete request was originally submitted. (Complete request is defined as all data elements are present and item has been defined by use.) E. The DMA will process the template and assign a completed status. The DMA will e-mail appropriate SIM routes, CMO coordinators, the original requestor, Materials Management directors, and other appropriate individuals maintaining order entry systems that the SIM has been added. F. Templates containing deletions will be communicated to appropriate SIM routes (including CMO coordinators, the original requestor, Materials Management directors, and other appropriate individuals maintaining order entry systems) that the item needs to be removed. Once all necessary deletions are completed at the facility, the information is communicated for the DMA to finalize deletion from the SIM. The DMA will send an email notification to the appropriate SIM routes once the BHS Master and individual hospital SIM have been modified. G. If one facility reuses an item that is disposable at another facility, a SIM number will be created for the item. The facility that reuses the item will use the SIM for statistical purposes only. H. It is the department director s responsibility to instruct staff and any other departments that will be using the new SIM number on its appropriate use, to educate users what changes were made and why, and how to appropriately use the affected SIM number. It is also the department director s responsibility to assure that all charge tickets are updated and revenue capture audits occur. I. The Compliance department will maintain documentation associated with the maintenance of the BHS Master SIM and the individual hospital's SIM. The documentation must be maintained for a minimum of seven years. 4
III. Maintenance of the Standardized Pharmacy SIM A. Requests for additions, changes and/or deletions to the Pharmacy SIM are to be submitted via template by the department director or designee to the STL according to the guidelines for approval. Once approved, the template is forwarded to Corporate Compliance. (see attached guidelines for STL approval) B. The DMA will review the template for needed action. If the request is for a new pharmacy item, the DMA will forward the template to the CMC for SIM assignment. If the request is for activation of an existing SIM number at an individual facility, the DMA will process the template. C. After receiving the template, the CMC will review the information and assign a SIM number, approve the addition/change of HCPC code, revenue code, etc., The CMC will forward the template to the DMA for addition/change to the Master SIM and hospital SIM. SIM maintenance should be completed no later than three (3) working days from the time the complete request was originally submitted. (Complete request is defined as all data elements are present and item has been defined by use.) D. The DMA will process the template and assign a completed status. The DMA will e-mail appropriate SIM routes, CMO coordinators, the original requestor, Pharmacy directors, Materials Management directors, and other appropriate individuals maintaining order entry systems that the SIM has been added. E. Templates containing deletions will be communicated to appropriate SIM routes (including CMO coordinators, the original requestor, Pharmacy directors, and other appropriate individuals maintaining order entry systems) that the item needs to be removed. Once all necessary deletions are complete at the facility the information is communicated for the DMA to finalize deletion from the SIM. F. It is the department director s responsibility to instruct staff and any other departments that will be using the new SIM number on its appropriate use, to educate users what changes were made and why, and how to appropriately use the affected SIM number. It is also the department director s responsibility to assure that all charge tickets are updated and revenue capture audits occur. G. The Compliance department will maintain documentation associated with the maintenance of the BHS Master SIM and the individual hospital's SIM. The documentation must be maintained for a minimum of seven years. 1V. HCPC/CPT Reviews and Regulatory Changes A. It is the responsibility of the department STL to assure that his/her peers are educated on an ongoing basis regarding the use of the CPT4 codes, HCPC Level II codes, and the purpose of appropriate codes. B. On an annual basis, when the new CPT/HCPC codes books are available, the CMC and appropriate STL are responsible for coordinating, scheduling and conducting meetings with peers from each functional area to discuss additions, deletions and changes that have been made. This meeting will be facilitated by the CMC. Representation from all hospitals is mandatory. DSA participation is encouraged. C. BHS IS is responsible for loading the new CPT-4 Codes and Descriptions into TPA no later than March 8 th. D. All requests for additions, changes and deletions must be documented, clearly indicating the effective date of the addition, change or deletion. The current template should be used for this communication and must be completed by February 28 th of each year. Compliance must have all changes completed by March 31 st each year to meet third party payer requirements. E. For regulatory changes, it is the responsibility of the CMC to notify the Compliance Officers and applicable department directors and STL of changes in reimbursement regulations that affect billing which occur between the annual updates. 5
F. It is the responsibility of each business office to ensure that all Medicare correspondence regarding CPT4 codes and diagnostic fee schedules are forwarded to the CMC, EDPFS, hospital department director and department STL within seven (7) working days of receipt. G. It is the responsibility of the CMC, department STL and department director(s) to discuss the information and decide on any changes that need to be made to current charging/billing practice within seven (7) working days of receipt. H. It is the responsibility of the STL to request the appropriate changes to the SIM utilizing the current template. I. It is the responsibility of the Compliance department to make the changes to the SIM within three (3) working days of receipt of the template. V. Billing Errors A. It is the responsibility of the hospital Business Office Manager or designee to review the claim to identify what the issue is. This may require contacting the insurance company to discern the actual issue. Once this has been done, the Business Office Manager or designee should notify (via e-mail) the EDPFS, CMC, department STL, other hospital business offices and applicable department director that billing errors are occurring because of CPT/HCPC codes or revenue code issues. B. The CMC will review the information available and discuss with the appropriate department director and/or STL. If the appropriate code is being used and billing errors are occurring, it is the responsibility of the CMC to review the information with the EDPFS. If all billing information is accurate, it is the responsibility of the CMC in conjunction with the EDPFS to contact the Fiscal Intermediary immediately to discuss the rejections. C. Within seven (7) working days of receiving the information from the Fiscal Intermediary, it is the responsibility of the CMC, department STL and department director(s) to discuss the information provided and make a decision on the appropriate action to be taken. D. It is the responsibility of the STL to request the appropriate changes to the SIM utilizing the current template. E. It is the responsibility of the CMC to sign off on CPT changes and for the DMA to make the appropriate changes in the BHS Master and all applicable hospital SIM masters. The documentation must be maintained for a minimum of seven years. VI. Miscellaneous SIM numbers A. Miscellaneous SIM numbers will be used only in the Pharmacy. A hospital may elect not to use Miscellaneous SIM numbers for pharmacy items. In this case, there will be a SIM requested for all Pharmacy items, even if the item is considered to be non-formulary. B. Usage of miscellaneous SIM numbers will be limited to those items that are considered to be non-formulary items and do not have a HCPC. Non-formulary medications are utilized when there is no formulary alternative available for the condition being treated. These may be a continuation of a patient s home therapy or treatment or rare conditions. Generally, non-formulary items are not routinely stocked in the pharmacy and the same item may only be used for 1-2 patients per year. C. These numbers will be limited to two one number for self-administered medications and one number for injectable medications. D. The Miscellaneous SIM number exception report will be reviewed daily by the hospital Pharmacist or designee to determine if a medication that is listed on the report has a HCPC code. If the item has a HCPC code, a SIM number will be requested via the current SIM template, even if the item will not be added to the hospital s formulary. 6
MONITORING PROCEDURE Exception reports that compare the Hospital SIM to the BHS Master will be reviewed weekly by the CMC or designee. Necessary corrections will be sent to the DMA via spreadsheet. The DMA will process all changes and forward the completed listing to the appropriate facility. The CMC will report exceptions to the Hospital Compliance Officers and the BHS Compliance Officer at least quarterly. Approved: BHS Compliance Officer Date: 7