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Charge Description Master and Revenue Integrity:
Putting the Pieces Together
Presented by:Catherine (Kate) H. Clark, CPC, CRCE-I
Vice PresidentMaryland AAHAM, Past President
Page 2
Objectives
This presentation will define and promote understanding of the following:
Charge Description Master (CDM) DefinedRevenue Integrity DefinedCDM Management OptionsRevenue Integrity, CDM, and the Revenue Cycle – How can we do it better?
Page 3
Polling Question #1
Respond to what role you play in relationship to the CDM/Revenue Integrity for your current position.
CDM Coordinator/ManagerCFO/CIO/COO/CEORevenue Cycle StaffFinance/Reimbursement StaffContractingCare/Case Management/CDI/DenialsOther
Page 4
Why Now?
Transition from Inpatient to Outpatient– Outpatient visits doubled from 1990-2010 (50%)– Inpatient admissions grew by 13%– Outpatient charges impacted by charge capture (% of charges =
Reimbursement)
Charge Capture Matters– Additional reimbursement– Accurate calculation of costs– Revenue Tracking by Department
Page 5
Why Now?
Electronic Medical Records (EMR)– Cleaning Up before EMR is built– Preparation = Less Clean-up– Crosswalk of a “constant” current state to EMR build– Departments are responsible for Reconciliation (Revenue
Integrity?)
Timing and Resources– January, October– Contracting updates for Non-Medicare payers– Updated Coding Guidelines– APC and HSCRC Updates
Page 6
Polling Question #2
In your opinion, what is the most important function of the CDM?
Charge CaptureComplianceDenials ManagementMedical Necessity VerificationPoint of Service CollectionsAccurate Claim SubmissionNone of the AboveAll of the Above
Page 7
CDM Defined
Charge Description Master (CDM)– A comprehensive listing of items billable to a hospital patient or
patient’s health insurance provider.
Master file built within the hospital information systems which is designed to interface with other software applications to support billing and reporting.Fields include (but are not limited to): – Revenue codes– Current Procedural Terminology (CPT) or HealthCare Procedural
Coding System (HCPCS)– Pricing– Service descriptions– Relative Value Units (RVUs) when applicable– Payer Specific Data Elements
Source: http://en.wikipedia.org/wiki/Chargemaster
Page 8
CDM Defined
CDM and the Claim Form
Has been described as “the central mechanism of the revenue cycle” of a hospital.
The CDM is closely linked to revenue generation. It is fundamental to the charge capture process.
Many CDMs are now being used as a component of revenue integrity validation.
Page 9
Revenue Integrity Defined
Purpose: to prevent recurrence of issues that can cause revenue leakage and/or compliance risk.
• Revenue Integrity focuses on process improvements
• Revenue Integrity provides a check/balance system for the revenue cycle components, with support from
leadership and technology.
Revenue Integrity– Stand-alone Department– Corporate Initiative– Organizational Structure
Page 10
Components of CDM/Revenue Integrity
Charge Master
CPT/HCPCSRates/PricingUnits of Service
ReimbursementPPS & Fee Schedules
General LedgerSupply Chain & Pharmacy Mgmt
Knowledge: Billing & Clinical
Complete & Correct Information = Paid Claims
Page 11
CDM Management Options
Components to Consider• Risk• Relationships• Compliance
CDM Team• Meeting Attendance – enforced by leadership
– Mandatory
• Composition of the Team– Who participates
• CDM Team Titles and Roles• CDM Staff
– Translator-Explanation of Roles– Manager– Coordinator– Analyst– Finance Staff
Page 12
CDM Management Options
Characteristics of effective CDM staff• Detail oriented• Inquisitive• Relentless• Highly organized• “Even” disposition• Good written and verbal communication
skills• Quick
Page 13
CDM Management Options – Set-Up
New Line Item Creation– Clinical– HIM– Rates and Reimbursement– Contracting– PFS– Financial Counseling/Patient Access
– Sign-Off of New Line Item by Impacted Areas• Are services provided billable? • Do they translate to CDM line items?• Each Department to sign-off (see above) must contribute with
their piece of the puzzle
Page 14
CDM Management Options
Enterprise vs. Single-Entity CDM Management– Size of CDM– Order Entry mapping to correct CDM lines
• Problematic for both entities, but moreso for Enterprise CDM
– Fee Schedule Management within CDM• Updates
– Multiple facility or enterprise builds with dedicated staff vs. single entity staff who are responsible for multiple roles.
– Electronic Health Record – controlled by whom– Are providers Regulated and Non-Regulated
Page 15
CDM Management Options
Internal vs. External CDM Management Options– Review goals of the CDM for organization– Cost of Vendor vs. Cost of Resources– Coordination of Information – NCD, LCD, Contracts– Implementation of changes– Communication with clinical staff– Information Technology interfaces– Data validation– Which option saves time or are more valuable?
Page 16
Revenue Integrity and Revenue Cycle
CHARGE CAPTURE
•MD ORDER ENTRY•SCHED & REG•ORDER ENTRY
BILLING•PAYER TABLE•CPT CODE•REV CODE •PRICING•RVU
HIM
•CPT CODES
BILLING ============PAYMENT=============PFS
Page 17
Revenue Integrity, CDM, & Revenue Cycle
CDM = Cash Flow– Updated CDM leads to faster cash
Scheduling– Clinical tests are scheduled based on CPT Codes– Patient balances calculated at time of scheduled procedure
Advanced Beneficiary Notice (ABN) Software– ABN executed based on CPT code assigned to test.– CPT is determined by CDM– Estimate patient balances if service is non-covered
• (All non-covered services do not require an ABN)
Pre-Authorization– Services are pre-authorized with insurance companies based on
the CPT code of the service.– Point of care collections – based on CDM pricing
Page 18
Revenue Integrity, CDM, & Revenue Cycle
Charge Capture – Electronic or Manual– Electronic = Interface of charges through systems– Manual = Direct data entry into billing module
• Both require accurate CDM set-up
– Preference List (clinical charges) to CDM• Charge Entry from Clinical Staff or Charge Staff• Set-up must be determined before Preference list build
– Order Entry Systems – Pyxis, Lab, Radiology, MUSE• Charge triggered based on parameters• Parameters defined by medical center, facility, or provider • Typically requires physician signature, physician order, or
nursing entry
Page 19
Revenue Integrity, CDM, & Revenue Cycle
Charge Capture – Electronic or Manual– Electronic Health Record (EHR) documentation
• Automatic generation of charges through completed documentation
– Encounter Forms• Completed by provider of care or designee• Manual entry into billing system• Typically direct data entry into billing system
– Professional Fees• Triggered from Facility CDM• Professional Provider CDM
Page 20
Revenue Integrity, CDM, & Revenue Cycle
UB-04 Claim Form– Billing of services performed to payers– Interface to billing systems or claim scrubber
software– Bridge Routines – what is built behind the scenes
for claim correction in order for them to be submitted to payers as “clean” claims.
Payer Tables– Compare patient insurance to payer information
tables within the CDM to ensure accurate revenue and CPT/HCPCS information on the claim form.
Page 21
Revenue Integrity, CDM, & Revenue Cycle
Health Services Cost Review Commission (HSCRC) (Maryland Hospitals Only)– HSCRC components are contained within the CDM as RVUs or prices
for drugs and supplies– Rate compliance within each Department reported to the HSCRC
Outpatient Prospective Payment System (OPPS)– Pricing of services based on reimbursement – Bundled services – still built separately in the CDM as needed– Outlier Payments
Denials Management/Cash Posting– Communication of payer needs through denials and interface back to CDM– Denied services are communicated to the provider of care using specific
HIPAA compliant denial codes.– Ongoing denial activity on specific line items must be communicated
back to the CDM Team.– Correct Coding Initiative (CCI) Edits
Page 22
Revenue Integrity, CDM, & Revenue Cycle
Health Information Management (HIM)– HIM coding of services within the hospital– No linkage to a specific CDM populated with CPT/HCPCS– HIM coded CPT/HCPCS codes must map to the appropriate revenue codes, which are
identified in the CDM. – CDM mapping to specific revenue codes allows HIM coded services to cross to the claim
form
Clinical Staff– Clinicians and Clinical Leadership must be involved with the set-up and
maintenance of the CDM.– Denied services are communicated to the provider of care using specific
HIPAA compliant denial codes.
Compliance– Each CDM that includes CPT/HCPCS, price, and quantity is subject to
evaluation for compliance with billing and coding rules.– Correct Coding Initiative (CCI) Edits– Payer Edits
REG
ULA
TIO
NS
PROCESS
CULTURE
TOOLS
PEOPLE
CDM and Revenue Cycle
BILLING
SCHEDULING
REGISTRATION
INSURANCEVERIFICATION
FINANCIALCOUNSELING
CASE MGMT/QUR
CDM/CHARGECAPTUREMEDICAL
RECORDS
CUSTOMER SERVICE
THIRD PARTYFOLLOW- UP
SELF PAYCOLLECTIONS
PROGRAMADMINISTRATI
ON
CASH POSTING
POSTPAYMENT REVIEW
TECHNOLO
GY
CU
STO
MER
EXPECTA
TIO
NS
PAYO
RS
POINT OF SERVICE
COLLECTIONS
DENIALS MANAGEMENT
FINANCIAL CLEARANCE
Adapted from -Source: http://healthdatamanagement.com/media
/RC101
COMPLIANCE
DependentRelated
Page 24
Revenue Integrity within Revenue Cycle
What is it…– How is it different from Charge Capture (only)– How is it measured?– What tools are used?– How does current workflow or culture impact
revenue integrity?– How do we know it is right?– Accountability– Oversight– Maintenance
Page 25
CDM and Revenue Integrity
Key Strategies• Create staff awareness• Provide tools and/or guidance• Design and implement a process for monitoring• Development of tools• Analysis of results to identify root causes• Develop corrective action plans• Track corrective action plan implementation• Verify improvement• Maintain oversight• Reporting to leadership.
Page 26
Polling Question #3
Has your facility performed a comprehensive CDM review within the past year?
Yes, completed using internal resourcesYes, using an outside firmYes, using both internal resources and outside firmNo, not within the past yearI Do Not Know
Page 27
CDM and Revenue Integrity - Strategies
When are CPT Codes and CDMs Updated– Is there a schedule for general CDM Updates– Outreach to clinical areas– Outreach to PFS
Baseline validation of the CDM by external company– HSCRC review of RVUs for CDM validation– Review of each clinical area ensuring the CDM is accurate– Ensure Operational workflow is supported by accurate CDM set-up
Crosswalks between systems must be up-to-date and accurate (current file maintenance reduces interface errors and manual corrections)– EHR mapping of charges– Interface with HIM– Order Entry mapping to the CDM– Preference Lists mapping to CDM– Charge Documents – including professional fee (in hospital setting)
Page 28
CDM and Revenue Integrity Strategies
Communication– Scheduling, Registration, Pre-authorization– Physicians, clinicians, or other providers– Patient Financial Services (PFS) – Facility and Professional– HIM, Denials, Nurse Auditors, CDI, Care/Case Management
Comprehensive CDM Review– Discussion
Education– Who teaches and relays the material– Who receives and is being trained on the material– What are the details of what is taught– How do you know the information is accurate
Page 29
CDM, Revenue Integrity, and You
What can you do…–Understand the chain of command–Gather Facts – Reports, examples,
data, results of queries–Communication – Not Personal, Direct,
Focused–Ownership of Findings–Follow-Up–Follow- Up (x2) if Issue Not Closed–Doing the Work vs. Doing it Well
Page 30
Final Comments
Reimbursement Methodology– Does not change the need for a compliant and current CDM and Revenue
Integrity Plan.
Updating the CDM– Policies and procedures– Code updates (at least 1x per year)– Inactivating or Added Services
Compliance Plan– Once a CDM policy and procedure is documented (frequency of review,
how new line items are created, consolidating the CDM), it must be followed.
– Revenue Integrity directly ties to compliance
Comment in Closing: – Stay current or you will never catch up
Questions
Thank You!
31
Catherine (Kate) Clark, CPC, CRCE-IVice President
Past President, Maryland [email protected]
(410) 979-1624
Kohler HealthCare Consulting, Inc.www.kohlerhealthcareconsulting.com
(410) 461-5116 – Office