WHAT IS A CDM? CDM: Finance and Compliance Concerns Hard copy and/or electronic listing of specific coding, pricing, descriptive and other information used to charge the patient and/or insurer for each hospital charge item, as a covered or non covered service. Idaho HFMA April 11, 2013 MOSS ADAMS LLP 1 MOSS ADAMS LLP 4 CDM COMPONENTS The material appearing in this presentation is for informational purposes only and is not legal or accounting advice. Communication of this information is not intended to create, and receipt does not constitute, a legal relationship, including, but not limited to, an accountant client relationship. Although these materials may have been prepared by professionals, they should not be used as a substitute for professional services. If legal, accounting, or other professional advice is required, the services of a professional should be sought. 1. Charge item (or billing) numbers 2. Descriptions 3. Prices 4. Department codes 5. General ledger codes 6. Revenue codes 7. HCPCS/CPT codes 8. Modifier codes (See attached from Medicare Claims Processing Manual Chapter 4 20.5.3, 20.6.8) 9. Other indicators (i.e. statistics, variable charge, exploding) 10. Effective dates MOSS ADAMS LLP 2 MOSS ADAMS LLP 5 OBJECTIVES 1. Maintaining and Auditing your CDM in a compliant manner 2. Proper UB04 claim form population related to CPT, HCPCS, Revenue Codes and Modifiers 3. Resources you can use to help maintain your CDM Process WHAT CONSTITUTES CDM ACCURACY? Charge item descriptions reflect service rendered and are understandable to the user CPT/HCPCS codes reflect service rendered Minimal unlisted codes Revenue codes are correct for service listed Medicare regulations Pricing CDM Maintenance Responsibilities next page MOSS ADAMS LLP 3 MOSS ADAMS LLP 6 1
Example CHARGE DESCRIPTION MASTER (CDM) Maintenance Responsibilities TASKS INDIVIDUAL DEPARTMENT PATIENT FINANCIAL SERVICES (PFS) ENTERING A NEW SERIVCE CHARGE INTO CDM ENTERING A NEW SUPPLY INTO CDM REVISING/DELETING CHARGES CODING CONTINUOUS VALIDATION OF CDM AND INSURING ALL CODES CORRECT i.e. MAINTENANCE Ensure all services provided have a valid charge set up in CDM PRIOR to rendering service Notify Central Authorization Dept. when changing CPT and/or HCPCS s so authorization grid can be updated. Submit item to be added to CDM, to include description, OE, charge department number After item is added to CDM, verify procedure code in OE matches procedure code in AR System(request CDM ) Contacts Materials Management Review annually & delete if not in use Select appropriate CPT For those procedures requiring alt HCPC add these codes in Other Ins code section Confer with HIM if CPT/HCPC codes unknown PRIOR to submission. If aware of change in codes, notify PFS Review request (Section A) for completeness. If incomplete return to department requesting additional information Verify charge is consistent with mark-up formula and forward request to HIS Forward to CDM Manager Add revenue code, HCPCS and CPT Notify HIS to send CDM to CDM consultant Notify department of changes identified by CDM consultant CDM MANAGER Verifies service/item is billable Indicate regional pricing If similar service/item already in CDM use same pricing / description Confirms correct codes have been assigned Verify CPT/HCPC codes with HIM Assign revenue code Quarterly review to validate accuracy of CDM to include deleted and new HCPC and CPT codes. Validate accuracy of CDM HOSPITAL INFORMATION SYSTEMS (HIS) Enters charges into AR System Add charges to OE/superbill Notifies department when charge is input and make available current CDM to manager Enter item into LAB, RAD as needed Enter billing code into MM item dictionary Add charges to OE/super bill Notifies department when charge is input and make available current CDM to manager Reviews/deletes (inactivates) as requested by PFS or department Submit CDM for review at end of each quarter
CHARGE DESCRIPTIONS SHOULD BE SIMPLIFIED Examples of how current descriptions can be changed to patient friendly descriptions: Ther/Proph/Diag IV Inf Int Elctrd EKG Inc/Rem FB SubQ-Simple Repr S-ficial 30cm OPV IV Infusion Initial Hour EKG Electrode Remove Foreign Body- Skin Repair Wound 30 CM Oral Polio Vaccine MOSS ADAMS LLP 7 WHERE IS THE CDM DATA GOING ON THE CLAIM FORM? FL 42 Revenue Code FL 43 Revenue Description FL 44 HCPCS/Accommodation Rates FL 45 Service Date FL 46 Service Units FL 47 Total Charges See sample UB04 form next page MOSS ADAMS LLP 8 1
1 2 3a PAT. CNTL # 4 TYPE OF BILL b. MED. REC. # 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD 7 FROM THROUGH 8 PATIENT NAME a 9 PATIENT ADDRESS a b b c d 10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 12 DATE 16 DHR 29 ACDT 30 13 HR 14 TYPE 15 SRC 17 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE e 31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH 38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a b c d 42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 23 PAGE OF CREATION DATE TOTALS 52 REL. 53 ASG. 50 PAYER NAME 51 HEALTH PLAN ID 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE INFO BEN. 56 NPI 22 23 A B C 57 OTHER PRV ID 58 INSURED S NAME 59 P.REL 60 INSURED S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. A B C A A B B C C 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A A B B C 66 DX 67 A B C D E F G H I J K L M N O P Q a b c 69 ADMIT 70 PATIENT 71 PPS 72 73 DX REASON DX CODE ECI 74 PRINCIPAL PROCEDURE CODE DATE a. OTHER PROCEDURE CODE DATE b. OTHER PROCEDURE CODE DATE 75 76 ATTENDING NPI QUAL LAST FIRST c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL LAST FIRST 80 REMARKS 81CC a 78 OTHER NPI QUAL b LAST FIRST 68 C c 79 OTHER NPI QUAL UB-04 CMS-1450 APPROVED OMB NO. d LAST FIRST THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. National Uniform NUBC Billing Committee LIC9213257
CUSTOMIZED APPROACH Develop a standard form and official sign off process Implement a CDM policy and procedure CDM Review a sample of itemized bills, UB 04, medical record, and remittance advise Maintenance Post implementation review of updated items Prioritize high volume and high dollar departments for CDM review Analyze and review pricing in the department, cost to charge ratio Evaluate the pricing adjustment affect on reimbursement, i.e. percent of billed charges, Pricing denials Adjustments Review of CDM, revenue and usage report, Medicare Fee Schedule, and Commercial and Managed Care payor contracts SURGERY: INTEGUMENTARY SYSTEM Revised o Tissue cultured epidermal autograft revised to skin autograft for consistency (APC 0134) 15150, 15151, 15152, 15155, 15156, 15157 CDM Process Develop process to update CDM quarterly and annually to comply with state and federal regulations By department: review CDM, update charge process, update charge policy and procedure, reconciliation process, and charge protocol manual Charge capture chart review to identify missing charges, duplicate charges, and supplies not coded MOSS ADAMS LLP 9 MOSS ADAMS LLP 12 CDM MAINTENANCE CDM Maintenance deals with multiple issues which are not mutually exclusive to each other. Review the CDM by department to ensure compliance and charge capture optimization Revision as new codes are deleted, modified, or added it is important to review the specific department CDM to ensure charging for services or items provided Update by add, change, or delete items and/or procedures Policy for new items/procedures Pricing Structure Documented in a policy Sample audit review to trend and track any possible revenue optimization opportunities MOSS ADAMS LLP 10 SURGERY: INTEGUMENTARY SYSTEM Added o Topical application of skin substitute graft to a wound surface (APC 0133 0135) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 o Implantation of biologic implant (APC 0136) 15777 MOSS ADAMS LLP 13 CDM MAINTENANCE: BY DEPARTMENT 1. Request a list of new, revised and deleted CPT & HCPCS codes each November. 2. Review the CDM within each Revenue Department. Ideal department team members include; manager, technical staff, charge capture/reconciliation staff and any billing/coding staff which support the department. 3. Review a sample of claims from recent services provided compared to the medical record documentation and EOBs. 4. Review any CPO screens or paper charge sheets/tickets. 5. Review revenue and usage report for department. 6. What are the department s long range plans? New service lines? MOSS ADAMS LLP 11 SURGERY: INTEGUMENTARY SYSTEM Revision of skin substitute guidelines Skin replacement surgery consists of o Surgical preparation and o Topical placement Autograft (including tissue cultured autograft) or Skin substitute graft (i.e., homograft, allograft, xenograft) Routine dressing supplies included MOSS ADAMS LLP 14 1
SURGERY: INTEGUMENTARY SYSTEM Surgical preparation example: o 75 sq cm wound on the right thigh o 75 sq cm wound on the left thigh Report first 100 sq cm as 15002 (APC 0135) Report second 50 sq cm as 15003 (APC 0135) For preparation of separately listed anatomical sites on the same day use modifier 59 SURGERY: INTEGUMENTARY SYSTEM Revision of skin substitute guidelines Skin substitute grafts (15271 15278) are not used to report: o Non graft wound dressing applications o Gel o Ointment o Foam o Liquid o Injected skin substitutes MOSS ADAMS LLP 15 MOSS ADAMS LLP 18 SURGERY: INTEGUMENTARY SYSTEM SURGERY: LUNGS AND PLEURA Revision of skin substitute guidelines o Autografts/tissue cultured autografts (15040 15157) include: (APC 0134 0137) Harvest autologous skin graft Removal of current graft Simple cleansing of the wound o Report debridement separately only for Prolonged cleansing required for gross contamination Removal of appreciable amounts of devitalized or contaminated tissue Separate debridement done without immediate primary closure MOSS ADAMS LLP 16 Deleted Describes New Codes Crosswalk 32095 Thoracotomy with biopsy 32096, 32097, 32098 (IP only) Infiltrate, nodule, pleura 32402 Open biopsy 32098 Pleura (IP only) 32500 Open wedge resection of lung 32505, 32506, 32507 (IP only) Therapeutic wedge resection 32602 Lung or pleural space biopsy 32607, 32608, 32609 Infiltrate, nodule, pleura (APC 0069) 32603 Diagnostic thoracoscopy, pericardial 32601 (APC 0069) sac, without biopsy 32605 Diagnostic thoracoscopy within the 32601 (APC 0069) mediastinal space 32657 Thoracoscopic (VATS) wedge 32666, 32667, 32668 (IP only) resection of lung 32660 Total pericardectomy MOSS ADAMS LLP 19 SURGERY: INTEGUMENTARY SYSTEM Revision of skin substitute guidelines (APC 0133 0135) Use skin substitute grafts (15271 15278) to report: o Non autologous (homograft, allograft) human skin grafts o Non human skin substitute grafts (i.e., xenograft) o Dermal o Epidermal o Cellular o Acellular o Sheet scaffolding biological project (for skin growth) MOSS ADAMS LLP 17 SURGERY: CARDIOVASCULAR SYSTEM Category III codes 0256T, 0258T and 0259T deleted and replaced with 33361 33365, 0318T for transcatheter aortic valve replacement (TAVR)/transcatheter aortic valve implantation (TAVI) o o Codes 33361 33365, 0318T include the work, when performed, of percutaneous access, placing the access sheath, balloon aortic valvuloplasty, advancing the valve delivery system into position, repositioning the valve as needed, deploying the valve, temporary pacemaker insertion for rapid pacing (33210), and closure of the arteriotomy when performed. Codes 33361 33365, 0318T include open arterial or cardiac approach. Angiography, radiological supervision, and interpretation performed to guide TAVR/TAVI (eg, guiding valve placement, documenting completion of the intervention, assessing the vascular access site for closure) are included in these codes. MOSS ADAMS LLP 20 2
SURGERY: NERVOUS SYSTEM EPIDURAL INJECTIONS Editorial clarifications to address concerns regarding inappropriate coding use of neuraxial catheters as single shot devices Editorial revision of 62310 and 62311 code descriptors Addition of instruction to clarify the difference between a single shot delivery via needle or catheter and a continuous or intermittent bolus delivery MOSS ADAMS LLP 21 CDM MAINTENANCE: BY CDM MANAGER/COMMITTEE 7. Annually review the Add/Change/Delete policy. 8. Review reports from PFS on claims denial activity as they related to coding and revenue codes. 9. Completing the review Reviewing all CPT and HCPCS codes for accuracy, validity, and relationship to charge description number Reviewing all charge descriptions for accuracy and clinical appropriateness Reviewing all revenue codes for accuracy and linkage to charge description numbers Ensuring that the usage of all CPT, HCPCS, and revenue codes are in compliance with Medicare guidelines or other existing payer contracts Reviewing all charge dollar amounts for appropriateness by payer Reviewing all charge codes for uniqueness and validity Reviewing all department code numbers for uniqueness and validity MOSS ADAMS LLP 24 SURGERY: NERVOUS SYSTEM EPIDURAL INJECTIONS 62310, 62311 single injection includes: (APC 0207) o Threading catheter into the epidural space o Injecting substances at one or more levels o Removing the catheter o Editorial revision of 62310 and 62311 code descriptors Codes 62310 62319 should be reported only once Percutaneous spinal procedures require imaging guidance or endoscopic visualization If open approach using endoscopic assistance, only codes 63020 63035 should be reported MOSS ADAMS LLP 22 CDM MAINTENANCE: SYSTEMS & PROCESSES Ongoing chargemaster maintenance as the facility adds or deletes new procedures, updates technology, or changes services provided Ensuring that all necessary maintenance to systems affected by changes to the chargemaster is performed when chargemaster maintenance is performed Performing tests to make sure that changes to the chargemaster result in the desired outcome Educating all clinical department directors on the chargemaster and the effect of the chargemaster on corporate compliance MOSS ADAMS LLP 25 CDM MAINTENANCE: BY CDM MANAGER/COMMITTEE 1. Request a list of new, revised and deleted CPT & HCPCS codes each November. Remember to watch for Quarterly HCPCS updates from CMS. 2. Review CMS fee schedule changes and commercial payor contracts. 3. Compile by department, CDM impact of changes from CPT and or HCPCS changes. 4. Analyze revenue and usage report. Prepare a listing of all Zero utilization codes. 5. For systems with outside CDMs, coordinate the review process. 6. What are the Facility s long range plans? New service lines? MOSS ADAMS LLP 23 WALKING THROUGH THE KEY ELEMENTS OF THE CDM REVIEW Key elements of the annual chargemaster review next page MOSS ADAMS LLP 26 3
CDM Annual Review Steps (adapted from AHIMA The Care and Maintenance of Chargemasters ) Key elements of the annual chargemaster review: 1. Reviewing all CPT and HCPCS codes for accuracy, validity, and relationship to charge description number 2. Reviewing all charge descriptions for accuracy and clinical appropriateness 3. Reviewing all revenue codes for accuracy and linkage to charge description numbers 4. Ensuring that the usage of all CPT, HCPCS, and revenue codes are in compliance with Medicare guidelines or other existing payer contracts 5. Reviewing all charge dollar amounts for appropriateness by payer 6. Reviewing all charge codes for uniqueness and validity 7. Reviewing all department code numbers for uniqueness and validity 8. Performing ongoing chargemaster maintenance as the facility adds or deletes new procedures, updates technology, or changes services provided 9. Ensuring that all necessary maintenance to systems affected by changes to the chargemaster (such as order entry feeder systems, charge tickets, and interfaces) is performed when chargemaster maintenance is performed 10. Performing tests to make sure that changes to the chargemaster result in the desired outcome 11. Educating all clinical department directors on the chargemaster and the effect of the chargemaster on corporate compliance 12. Establishing a procedure to allow clinical department directors to submit chargemaster change requests for new, deleted, or revised procedures or services 13. Ensuring there is no duplication of code assignment by coders and chargemasterassigned codes in any department (e.g., interventional radiology or cardiology catheterization laboratory) 14. Reviewing all charge ticket and order entry screens for accuracy against the chargemaster and appropriate mapping to CPT or HCPCS codes when required 15. Reviewing and complying with directives in Medicare transmittals, Medicare manual updates, and official coding guidelines 16. Complying with guidelines in the National Correct Coding Initiative, Outpatient Code Editor edits, and any other coding or bundling edits 17. Considering carefully any application that involves one charge description number that expands into more than one CPT or HCPCS code to prevent inadvertent unbundling and unearned reimbursement for services 18. Reviewing and taking action on all remittance advice denials involving HCPCS or CPT coding rules and guidelines or CMS payer rules 19. Educating all staff affected by changes to the chargemaster in a timely fashion
CDM MAINTENANCE: COMPLIANCE FROM THE FIELD 26 Claims reviewed from the Cath Lab Incorrect Charges/Billing Errors 9 of 26 claims reviewed had incorrect charges resulting in incorrect billing and incorrect cost of the procedure performed. The dollar impact is $874.44 in lost Medicare revenue. Incorrect Charge by Clinical Department In 9 of 26 claims reviewed, we observed incorrect charges by the Clinical Department including: 1 Pyxis Chargemaster error leading to incorrect units and incorrect charge capture of units for contrast media and a missed stent charge. The missing stent charge did cause the claim to receive a fatal error as it is required to be reported when a stent placement procedure is reported. FINDINGS Issue Observation Recommendation Incorrect HCPCS Code In 17 instances the Send corrected claims to incorrect HCPCS code J1950 was assigned for Medicare for each error identified in the review. the drug. Pharmacy Complete additional review noted they corrected the incorrect HCPCS code in May 2012 (which is after the dates of the patients who have recurring accounts to ensure proper HCPCS were reported on the claim(s). of service selected for Validate the May 2012 review). It was unclear if the correction has resolved the issue. corrective steps taken in Review all claims with the May 2012 were validated HCPCS J1950 for a period of four years to ensure the proper HCPCS is billed. MOSS ADAMS LLP 27 MOSS ADAMS LLP 30 FINDINGS Issue Observation Recommendation Off Label Drug Use In two instances, offlabel drug use was Medicare for each confirmed Send corrected claims to administered. Neither error identified in the review. Medicare Contractor The hospital pharmacy prior approval nor use should obtain a CMS of official Compendia Approved Compendia. was available The hospital should actively work with the Medicare Contractor to obtain prior approval for off label use of medications. The approval for off label use should be distributed to medical staff, compliance, billing and coding departments. Cont. MOSS ADAMS LLP 28 CDM MAINTENANCE: COMPLIANCE FROM THE FIELD Quick review of a Medicare PSR for Outpatient Claims Revenue Code 0272 Sterile Supplies This revenue code appeared to have a disproportion of total charges when compared to 0275, 0276 and 0278 Revenue Code 0335 Chemotherapy Infusion The small number of units reported did not appear to correlate to the Chemo drugs reported with 0636 Revenue code 0481 Cath Lab The volume of services reported did not appear to correlate to the charges reported in 0275 or 0278. Revenue code 0636 Drugs requiring detail coding The number of units reported divided by the total dollars reported showed the average drug charge was below $8.00. MOSS ADAMS LLP 31 FINDINGS Issue Observation Recommendation Incorrect HCPCS Code For Lupron In 17 instances the incorrect HCPCS code J1950 was assigned for the drug. Pharmacy noted they corrected the incorrect HCPCS code in May 2012. It was unclear if the corrective steps taken in May 2012 were validated. Send corrected claims to Medicare for each error identified in the review. Consider adding use in the CDM description. Validate the May 2012 correction has resolved the issue. Review all claims with the HCPCS J1950 for a period of four years to ensure the proper HCPCS is billed. CDM MAINTENANCE: COMPLIANCE FROM THE OIG Review current Fiscal Year OIG Workplan. Medicare Inpatient and Outpatient Hospital Claims for the Replacement of Medical Devices Modifiers FB and FC Hospital Claims With High or Excessive Payments Our work will include certain outpatient claims in which payments exceeded charges and selected Healthcare Common Procedure Coding System codes for which billings appear to be aberrant. Medicare requires hospitals to report units of service as the number of times a service or procedure was performed. Hospital Inpatient Outlier Payments: Trends and Hospital Characteristics Recent whistleblower lawsuits have resulted in millions of dollars in settlements from hospitals charged with inflating Medicare claims to qualify for outlier payments. MOSS ADAMS LLP 29 MOSS ADAMS LLP 32 1
CHANGE REQUEST 7771 Fiscal Intermediary Standard System (FISS) edit to review Medicare Outpatient Prospective Payment System (OPPS) payments exceeding charges Effective October 1, 2012 FISS reason code 39132 o Claims are suspended for accurate billing verification o If inaccuracies are found, claim will be returned for claim correction or remarks Most frequent services receiving the edit are drugs MOSS ADAMS LLP 33 PRICING ADJUSTMENTS Keys to a Successful Price Adjustment Process Analyze and evaluate the entire CDM for appropriate and compliant rate adjustments Review Payor Mix Assess pricing in geographical area Assess cost to charge ratio Create a best practice methodology to evaluate annually Develop and implement a formal policy and procedure, and process for rate adjustments MOSS ADAMS LLP 34 PRICING ADJUSTMENTS BASED ON CONTRACTS Keys to ensure a smooth claims adjudication process Contract Matrix use it! Or create one! See Sample Hospital Rate Matrix Handout MOSS ADAMS LLP 35 2
General Hospital Medicare #, Tax id # Revised DATE Type of Agreement (HMO, PPO, etc) Rate Effective Date Rate Expiration Date Original Contract Effective Date Auto Re-New/Evergreen Plan code/financial Class Termination Notice Timely Filing for Initial Claim (days) Appeals Commercial Plan A Commercial Plan B HMO, PPO, Psych Medicare C Plan 6/30/2010 1/1/2011 6/30/2011 12/31/2011 6/30/2010 1/1/2011 Auto-Renewed Auto-Renewed 180 180 at the end of the initial term 120 120 365 days per State regs 365 days per State regs Prior Authorization / Notification Required in accordance with provider manual see www.xxxx.com for provider manual in accordance with provider manual see www.xxxx.com for provider manual Midnight Rule (if pt in bed @midnight, do IP rates apply?) if patient stays 24 hours they are an inpatient. Less than 24 hours, they are an outpatent if patient stays 24 hours they are an inpatient. Less than 24 hours, they are an outpatent Inpatient Type Amount Type Amount Inpatient Services (all, if not defined below) Billed Charge 70% NTE/Day $ 9,600 Administrative Day Cardiac Procedures Cardiac Surgery Cardiac Cath PTCA Neurosurgery Orthopedic Surgery/Spine Surgery Maternity -Vaginal PD, Mom only $ 5,200 Maternity -C-Sect PD, Mom only $ 5,400 Current Medicare Allowable 100% Boarder Baby/Newborn Nursery Newborn Level 2 Newborn Level 3 (Sick Neonate) Newborn Level 4 (NICU) Lower Level Neonate by MS-DRG PD, Rev Code 170,171,179 and ICD 9 Dx V65.0 or V20.1 $ 1,250 PD, MS DRG 789,792,794 $ 7,295 Higher Level Neonate by MS-DRG PD, MS DRG 791,793 $ 9,155 Severe Level Neonate by MS-DRG PD, MS DRG 790 $ 13,525 All Inpatient Trauma Psych - Mental Health Billed Charge (entire stay), Rev 68x or type of admission = 05 (in field locator 14 on UB) 75%
Commercial Plan A Commercial Plan B Adult ECT Inpatient Chemical Dependency Lithotripsy Sub Acute Exclusions: Implants/Prosthetics Billed Charge; Rev 274-276,278 50% NTE cost plus 5% Stoploss (Catastrophic) Excl from threshold implants, all trauma excluded Threshold Threshold $ 175,000 % payable % payable 70% Method Method 1st dollar OUTPATIENT Type Amount Type Amount Billed Chg (incl hosp based clinics, infusion Current Medicare All Other Outpatient Services clinic) 60% Allowable 100% Other, Not defined, Billed Charge 18% Ambulatory Surgery Billed (rev code 36*,481,49*,75*,79*) 60% NTE per case $ 19,000 Multiple Proc 100%/100%/100% ER Services Billed 60% Urgent Care (Freestanding Rev 516,526) OB False Labor Chemotherapy Billed, CPT 51720,96401-96542 40% also includes Chemo Drugs (Jxxx) OP Lab OP Radiology Billed, CPT 70010-79999 57.8% Radiation Therapy Trauma Billed, Rev 681-684, 689 75% Ambulance Land Ambulance Air Psych - Mental Health Full Day Partial (min 6 hrs) Psych - Mental Health Half Day Partial (< 6 hrs) Crisis Observation Exclusions: Billed Charge; Rev Implants/Prosthetics 274-276,278 50% Pharmacy Worker's Compensation Type Amount Type Amount State WC Fee Schedule
PATIENT FRIENDLY BILLING GUIDING PRINCIPLES FROM HFMA PATIENT FRIENDLY BILLING PROJECT Price is important Rational pricing requires collaboration and communication Market forces affect prices Cost is an important component Quality must be integrated into system Rational pricing requires clear structure Prices must cover financial requirements Centralized pricing preferable MOSS ADAMS LLP 36 HOW TO PRICE: OPTIONS OR Time/Minutes Do you have stats drive by costs for procedures? Do you have wheels out/in times or close to cut stats? Many facilities have grouped like type procedures with similar average costs into categories such as: Ortho Minor Ortho Major ENT Ophthalmology Cardiac Cath diagnostic only Cardiac Cath with procedure Usually the first 15minutes of time is heavily loaded with charges with each incremental minute or unit at much lower incremental charge Per Type Charge one time charge, without incremental units MOSS ADAMS LLP 39 COMMON THEMES FOR BETTER PRICING FROM HFMA PATIENT FRIENDLY BILLING PROJECT FACILITY E&M CHARGES Meaningful, timely, and relevant information to consumers on demand: Simplicity Defensible Fairness to those with limited ability to pay Comparability of price and quality Ease and equity of administration Equity for providers Efficiency Emergency Department Visit (99281 99285, 99291) Clinic and Outpatient Departments (99201 99215) CMS says next page MOSS ADAMS LLP 37 MOSS ADAMS LLP 40 HFMA SAYS (PATIENT FRIENDLY BILLING) ASSESS THE IMPACT OF PRICE CHANGES Factor cost, market data, and payment into your models Assess how the changes will impact the private contracts that make the majority of your revenue Identify direct costs and their relationship to the final price Identify market data on the procedures that generate 80% of revenues Perform market analysis annually Review proposed price changes with community stakeholders Seek legal counsel first! MOSS ADAMS LLP 38 1
Update on hospital clinic and emergency department visit coding Coding Clinic for HCPCS, Fourth Quarter 2007 Page: 1-3 Every effort is made to provide accurate coding advice on HCPCS for the institutional provider setting to coincide with national Medicare instructions. This advice does not dictate coverage and reimbursement policy as determined by local Medicare contractors or any other payer; nor is it a substitution for the judgment of a qualified practitioner in the application of HCPCS codes. This article was developed to provide a summary of the highlights related to the coding of hospital clinic and emergency department visits, as published in the CY 2008 Outpatient Prospective Payment System (OPPS) final rule that was published in the Federal Register on November 27, 2007. Guideline Principles CMS has identified 11 principles that hospitals internal coding guidelines for visit coding are expected to follow. The first six principles have been reaffirmed, while the next five have been newly added for CY 2008. 1. Guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code; 2. Guidelines should be based on hospital facility resources, not physician resources; 3. Guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits; 4. Guidelines should meet the Health Insurance Portability and Accountability Act (HIPAA) requirements; 5. Guidelines should only require documentation that is clinically necessary for patient care; 6. Guidelines should not facilitate upcoding or gaming. 7. Guidelines should be written or recorded, well-documented and provide the basis for selection of a specific code; 8. Guidelines should be applied consistently across patients in the clinic or ED to which they apply; 9. Guidelines should not change with great frequency; 10. Guidelines should be readily available for fiscal intermediary (or, if applicable, Medicare administrative contractor) review; and,
11. Guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources. CMS provided clarification regarding these principles as follows: Hospital-specific guidelines should not be based on physician resources. However, this does not preclude a hospital from using or adapting the physician guidelines if the hospital believes that such guidelines adequately describe hospital resources. Hospitals with multiple clinics may have different coding guidelines for each clinic, but the guidelines must be applied uniformly within each separate clinic. Hospital s assorted set of internal guidelines must measure resource use in a relative manner, in relation to each other. CMS would generally expect hospitals to adjust their guidelines less frequently than every few months, and they believe that it would be reasonable for hospitals to adjust their guidelines annually, if necessary. Hospitals should use their judgment to ensure that coding guidelines are readily available, in an appropriate and reasonable format. CMS would encourage fiscal intermediaries (FI) and Medicare Administrative Contractors (MACs) to use the hospital s internal guidelines as a reference when auditing the hospital s ED and clinic records. Hospitals should use their judgment to ensure that their coding guidelines can produce results that are reproducible by others. Hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. Hospitals with more specific questions related to the creation of internal guidelines are encouraged to contact their local FI or MAC. CMS will continue to work on national guidelines and they continue to encourage comments and submissions of successful models. In the meantime, they will require each hospital s internal guidelines to meet the 11 principles stated above.
CDM PROCESS IN SUMMARY A comprehensive process for charge capture and revenue optimization. By department update pricing, description, CPT,HCPCS, and Revenue Codes Update charge sheet/screens to ensure charge capture Assess annual price adjustments to optimize reimbursement and remain competitive for services Implement and monitor charge reconciliation process to optimize revenue and reimbursement Complete department CDM review and update ICD codes annually/cpt and HCPCS codes quarterly MOSS ADAMS LLP 41 QUESTIONS? Peggi Ann Amstutz, MBA, CCS-P, CCS AHIMA Approved ICD-10-CM/PCS Trainer 253-284-5299 peggi-ann.amstutz@mossadams.com MOSS ADAMS LLP 42 1
The Integrated Outpatient Code Editor (I/OCE) accepts all valid CPT and HCPCS modifiers on OPPS claims. Definitions for the following modifiers may be found in the CPT and HCPCS guides: Level I (CPT) Modifiers -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79, -91 Level II (HCPCS) Modifiers -CA, -E1, -E2, -E3, -E4, -FA, -FB, -FC, -F1, -F2, -F3, -F4, -F5, -F6, -F7, -F8, -F9, -GA, -GG, -GH, -GY, -GZ, -LC, -LD, -LT, -QL, -QM, -RC, -RT, -TA, -T1, -T2, -T3, -T4, -T5, -T6, -T7, -T8, -T9 As indicated in 20.6.2, modifier -50, while it may be used with diagnostic and radiology procedures as well as with surgical procedures, should be used to report bilateral procedures that are performed at the same operative session as a single line item. Modifiers RT and LT are not used when modifier -50 applies. A bilateral procedure is reported on one line using modifier -50. Modifier -50 applies to any bilateral procedure performed on both sides at the same session. NOTE: Use of modifiers applies to services/procedures performed on the same calendar day. Other valid modifiers that are used under other payment methods are still valid and should continue to be reported, e.g., those that are used to report outpatient rehabilitation and ambulance services. Modifiers may be applied to surgical, radiology, and other diagnostic procedures. Providers must use any applicable modifier where appropriate. Providers do not use a modifier if the narrative definition of a code indicates multiple occurrences. EXAMPLES: The code definition indicates two to four lesions. The code indicates multiple extremities. Providers do not use a modifier if the narrative definition of a code indicates that the procedure applies to different body parts. EXAMPLES: Code 11600 (Excision malignant lesion, trunks, arms, or legs; lesion diameter 0.5 cm. or less)
Code 11640 (Excision malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm. or less) Modifiers -GN, -GO, and -GP must be used to identify the therapist performing speech language therapy, occupational therapy, and physical therapy respectively. Modifier -50 (bilateral) applies to diagnostic, radiological, and surgical procedures. Modifier -52 applies to radiological procedures. Modifiers -73, and -74 apply only to certain diagnostic and surgical procedures that require anesthesia. Following are some general guidelines for using modifiers. They are in the form of questions to be considered. If the answer to any of the following questions is yes, it is appropriate to use the applicable modifier. 1. Will the modifier add more information regarding the anatomic site of the procedure? EXAMPLE: Cataract surgery on the right or left eye. 2. Will the modifier help to eliminate the appearance of duplicate billing? EXAMPLES: Use modifier 77 to report the same procedure performed more than once on the same date of service but at different encounters. Use modifier 25 to report significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Use modifier 58 to report staged or related procedure or service by the same physician during the postoperative period. Use modifier 78 to report a return to the operating room for a related procedure during the postoperative period. Use modifier 79 to report an unrelated procedure or service by the same physician during the postoperative period. 3. Would a modifier help to eliminate the appearance of unbundling? EXAMPLE: CPT codes 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) and 36000 (Introduction of needle or intra catheter, vein): If procedure 36000 was performed for a reason other than as part of the IV infusion, modifier -59 would be appropriate.