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Advanced Charge Master Strategies AdvancedAdvanced ChargeCharge MasterMaster StrategiesStrategies HFMA Western NY Chapter January 26-27, 2010 IntroductionsIntroductions Mike Kovar is a Partner in Tatum LLC’s Health Care Consulting Practice. He has led over 400 charge master, revenue capture, and patient charge compliance reviews. He received his Masters’ in Business Administration from Loyola University of Chicago, is an advanced member of HFMA, and is a frequent speaker nationally on charge master and other revenue capture- related issues. Colleen Hall is a Principal in the Health Care Practice of Tatum LLC. She has over 8 years of experience in the health care industry with a primary focus in charge capture and charge master analyses for hospital providers. Colleen has Big Four consulting experience as well as management experience with physician offices. Colleen is also a Certified Professional Coder (CPC). 2 ObjectivesObjectives ofof thethe SeminarSeminar In our two day session, we will cover the following: CY 2010 CPT Changes CY 2010 OPPS Final Rule Latest on Health Care Reform Advanced charge capture strategies to ensure optimal reimbursement under the Medicare OPPS system and for other third-party payors 3 ChargeCharge MasterMaster What is the Charge Master? The charge master is the price book for the hospital. It provides the link between service delivery and billing. Is critical to the accurate billing of patient care services. Is critical in decision support functions. 4 ChargeCharge MasterMaster Charge master affects other systems Order entry Ancillary department systems such as RIS, LIS and Pharmacy systems Bill editors/scrubbers 5 WhatWhat IsIs InIn thethe ChargeCharge Master?Master? Service Code — It usually includes department number or a link to the department number. Description — Misconception that description seen in order entry or on charge sheet is what is on the bill. Description should be user friendly for patient accounting staff as well as patients. CPT Code (5-digit numeric code) or HCPCS Code (Alpha-digit plus 4 numeric digit code) — Either CPT Code or HCPCS Level II Codes are described in AMA CPT Code Manual or HCPCS Manual. UB-04 Revenue Code (4 digit code) — Links typically to CPT code and is pointer to clinical department where the service is provided. Price — It is the dollar amount billed to the patient/payor. 6 WhyWhy IsIs thethe ChargeCharge MasterMaster Important?Important? Appropriate Reimbursement Accurate Charge Master Billing Service Analysis Compliance (Decision Support) 7 OtherOther ChargeCharge MasterMaster ConceptsConcepts Billable versus non-billable -Medicare vs other payors -Hot and cold packs Fee Schedules - Medicare OPPS - Medicare Clinical Laboratory - Medicare Physician - Medicare Therapy Services - Other Payors 8 CPT/RevenueCPT/Revenue CodingCoding ConceptsConcepts CPT Codes-Category I CPT Codes-Category II -Quality measurements CPT Codes-Category III -New Technology HCPCS National Level II Codes Revenue Codes-Four digit numeric designating department where service provided 9 ChargeCharge MasterMaster CodingCoding Current Procedural Terminology or CPT Codes (Level I/Category I CPT)) Maintained and updated annually by the American Medical Association. New updated code manuals provided in November of each year. CMS now requires all CPT Coding revisions to be implemented by January 1. Focus on Appendix B of the CPT Coding Manual — Summary of Additions, Deletions, and Revisions — when evaluating the necessary changes to the charge master. CPT Code Categories: 9 Evaluation and Management CPT Codes 99201 – 99499 9 Anesthesia CPT Codes 00100 – 01999 9 Surgery CPT Codes 10021 – 69990 9 Radiology CPT Codes 70010 – 79999 9 Pathology & Laboratory CPT Codes 80048 – 89399 9 Medicine CPT Codes 90281 – 99199 Stay away from using the “unlisted procedure” codes XX999 – often misused by Hospitals. Look for CPT Codes with a (+) next to them — these are add-on procedures. CPT Codes can be hard coded in the charge master. (e.g., Laboratory, Radiology) or they can be assigned by Health Information Management (HIM) via the abstracting system (e.g., Operating Room Services). 10 ChargeCharge MasterMaster CodingCoding Healthcare Common Procedure Coding System or HCPCS Codes (Level II) Maintained and revised throughout the year by the Centers for Medicare and Medicaid Services, or CMS. New HCPCS codes are effective January 1 of each year. HCPCS Code Categories: 9 A Codes A0021 – A9901 Transportation services, including ambulance, medical and surgical supplies and miscellaneous 9 B Codes B4034 – B9999 Enteral and Parental Therapy 9 C Codes C1000 – C9999 Temporary codes for use with OPPS 9 D Codes D0000 – D9999 Dental procedures 9 E Codes E0100 – E9999 Durable Medical Equipment 9 G Codes G0000 – G9999 Procedures and Professional Services 9 H Codes H0001 – H1005 Alcohol and Drug Abuse Treatment Services 9 J Codes J0120 – J8999 Drugs Administered Other Than Oral Method 9 K Codes K0000 – K9999 Durable Medical Equipment Regional Carriers 9 L Codes L0100 – L9999 Orthotic and Prosthetic Procedures 9 M Codes M0000 – M0302 Other Medical Services 9 P Codes P0000 – P9999 Pathology and Laboratory Services 9 Q Codes Q0000 – Q9999 Temporary 9 R Codes R0000 – R5999 Diagnostic Radiology Services 9 S Codes S0009 – S9999 National Codes (Non-Medicare) 9 T Codes T1000 – T2007 National Codes for State Medicaid Agencies 9 V Codes V0000 – V5999 Vision and Hearing Services 11 ChargeCharge MasterMaster CodingCoding CPT and HCPCS Level II Modifiers Required by CMS to be reported for outpatient services Varying methods of modifier assignment: 9 Hard coded in the charge master 9 Assigned by HIM through the abstracting system 9 Assigned by the department staff through the charge entry system Modifiers required: Level I (CPT) Level II (HCPCS) -25 -59 -78 -CA -FA -F5 -GA -LC -RC -T3 -T8 -27 -73 -79 -E1 -F1 -F6 -GG -LD -RT -T4 -T9 -50 -74 -91 -E2 -F2 -F7 -GH -LT -TA -T5 -52 -76 -58 -E3 -F3 -F8 -GY -QM -T1 -T6 -77 -E4 -F4 -F9 -GZ -QN -T2 -T7 Assignment of correct modifiers can be critical to reimbursement. + e.g., 25 modifier 12 ModifierModifier BasicsBasics Modifiers are intended to notify payors that: -A service was provided by more than one physician and/or one location -A service was reduced or increased -A service was partially completed -An adjunctive service was performed -A bilateral procedure was performed -A service was performed more than once -Unusual circumstances occurred Commonly used Level I modifiers for OPPS include 25, 27, 50, 52, 59, 73, 74, 76, 77, and 91 Level II modifiers include LT, RT, CA, E1-E4, FA, F1-F9, GG, GH, LC, LD, RC, TA and T1-T9 Determine who assigns each modifier at your hospital -Is it hard-coded in the CDM, OE or the ancillary system (RIS)? -Is HIM assigning modifiers? -Is Patient Accounting assigning modifiers? Are the clinical departments involved? How do we monitor and track modifier assignment? (i.e. “59” modifier) 13 ModifierModifier BasicsBasics 25 modifier-Significant, Separately Identifiable E&M Service by Same Physician on Same Day of a Procedure: -Commonly used in ED 27 modifier-Multiple OP Hospital E&M Encounters on Same Date -Used in ED and clinics 50 modifier-Bilateral Procedure -Used if bilateral is not indicated in the CPT description 52 modifier-Reduced Service -Payment may be reduced 59 modifier-Distinct Procedure or Service -Frequently misused to bypass CCI edits 73 modifier-Discontinued OP Procedure prior to Anesthesia 74 modifier-Discontinued OP Procedure after Anesthesia 76 modifier-Repeat Procedure Same Physician 77 modifier-Repeat Procedure Different Physician 91 modifier-Repeat Clinical Laboratory Diagnostic Test Level II HCPCS modifiers indicate “body location” of the service such as T1 left foot, second digit, etc. 14 ChargeCharge MasterMaster CodingCoding CPT Category III Codes Maintained and updated semiannually by the AMA Temporary codes for emerging technologies, services, and procedures If a Category III Code is available, this code must be reported instead of a Category I unlisted CPT Code. These codes have a alpha character as the fifth digit (“T” now in use) Category III Codes are archived 5 years after inception Category Code III assignment does not imply coverage by Medicare Examples of Category III Codes include: 9 0003T Cervicography 9 0028T DEXA Body Composition scan 9 0066T CT colonography screening 15 OverviewOverview ofof APCsAPCs In 2000, Medicare implemented the Outpatient Prospective Payment System (OPPS) for hospital outpatient services. Key Differences Pre- vs. Post-OPPS Pre Post Reimbursement based upon Reimbursement based upon Ambulatory Patient cost in most cases Classification (APC) fee except Laboratory and schedule for all areas except Rehabilitation Laboratory and Rehabilitation Capturing of all charges and having If costs captured, you would the correct CPT Coding assigned is probably be ok from a critical to reimbursement. The APC reimbursement perspective assigned for payment is determined by the CPT Codes. Capturing all the appropriate charges and ensuring that all the correct CPT/HCPCS codes appear on the patient bill is now critical to reimbursement. 16 OverviewOverview ofof APCsAPCs Key Reimbursement Methodology Previous Medicare Outpatient Medicare Outpatient PPS Ancillary Area Reimbursement Methodology Reimbursement Methodology Radiology Cost Based APC Clinical Laboratory Fee Schedule Fee Schedule Anatomic Pathology/ Cytology Cost Based APC Cardiology Cost Based APC Pharmacy Cost Based APC Supplies Cost
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