2011 CDM Updates Day 1

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Part 1 of 2 day workshop presented to the Western New York chapter of HFMA.

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  • 1. HFMA Western NY ChapterJanuary 25, 2011 Day 12011 OPPS UPDATES, CODING CHANGESAND CHARGE MASTER APPROACHES

2. INTRODUCTIONSCaroline Rader, Associate Director Ms. Rader has approximately 15 yearscombined of industry and professional consulting experience related to chargeintegrity services; including but not limited to, charge description mastermaintenance, charge capture strategies, outpatient clinical documentationimprovement, and billing compliance. She serves many of the top hospitals inthe nation on related topics including Johns Hopkins Health System, NovantHealth, University of Maryland Medical System, Caritas Christi and MedStarHealth. Ms. Rader is also recognized as a state and national speaker for HCCA,HFMA, ACDIS and AHIMA.Deborah Zarick, Associate Director Ms. Zarick has both a clinical and codingcompliance background. She has many credentials including R.N, B.S.N, CPC,CCS-P, CEMC, CPC-I, and CPMA. She leads NCIs physician coding services,providing consulting to such clients as University of Maryland Medical System,Lifebridge Health, Loyola and Stanford Medical Clinics. 2 3. OBJECTIVES OF THE WORKSHOP2011 includes 400 CPT revisions, deletions, and additions. In order toavoid claim denials and coding errors as well as capture revenue foraccurately documented services, it is critical that you keep current onrelevant and significant updates to CPT as well as HCPCS codes.The workshop will address specific code changes, the rationale behind thechange, and the impact these changes will have on your charge descriptionmaster. The work shop will cover the items below by clinical department:2011 CPT and HCPCS updateCharge Capture StrategiesTips for Auditing and MonitoringRegulatory Update and Considerations CPT is registered trademark of the American Medical Association. All rights reserved.3 4. OBJECTIVES OF THE WORKSHOPAfter attending this meeting, participants should be able to:Implement the new OPPS rules into day to day operations;Cite important HCPCS/CPT coding changes for 2011;Describe the use of new codes;Identify target areas for investigation;Analyze current use of the charge description master to identifyopportunities for improvement in charge capture, andImplement office policies and procedures to ensure compliance withfraud and abuse regulations and statutes. 4 5. CHARGE DESCRIPTION MASTERThe charge description master (CDM) is a file that contains alist of a providers chargeable services.Hospital facilities can assess a patient charge for visits,procedures, medications and supplies.A current and accurate CDM is vital to any healthcareprovider seeking proper reimbursement.Among the potential negative impacts that may result froman inaccurate charge master are overpayments,underpayments, claim rejections, civil monetary fines andpenalties.5 6. CHARGE DESCRIPTION MASTERIn addition to the list of services, the CDM electronic fileincludes the following: unique reference identifier the procedure or service description the appropriate HCPCS/CPT code (if available) the UB-04 revenue code number unit of service and/or multiplier corresponding charge dollar amount. CDM HCPCS/UB04 RevCharge CDM Service Description UOSNumberCPTCode Amount 4500100 ED VISIT LEVEL I99281 450 1 $200.00 6 7. CHARGE DESCRIPTION MASTERUnique Reference Identifier - An internally assigned uniquenumber that identifies each specific procedure or service listed on thecharge master.Procedure or Service Description - This designation describes theprocedure or service to be performed.HCPCS/CPT Code - The corresponding HCPCS/CPT code thatidentifies the specific line item service or procedure. Level I Category I - CPT Codes Level I Category II Quality Measurements Level I Category III New Technology Level II HCPCS National Codes7 8. CHARGE DESCRIPTION MASTERUB-04 Revenue Code - A three-digit code number representing aspecific accommodation, ancillary service, or billing calculation requiredfor facility billing.Unit of Service/Multiplier In most cases the service unit of servicewill default to a unit of 1 and the line item is charged per each service.However, some instances will occur where the line item service or itemis provided or dispensed in multiple units.Charge Dollar Amount - The specific amount charged by the facilityfor each procedure or service. This is not the actual amount that thefacility will be reimbursed by a third party payer. Instead, the chargedollar amount represents the standard charge for that item. 8 9. CHARGE DESCRIPTION MASTERServices and/or items found in the CDM can either be hard-coded or soft-coded. To hard-code a service or item is to include the HCPCS/CPT in the CDM.The service or item is coded automatically and no human intervention isrequired.Hard-coding should be used only for the services that lack variability in theirapproach, performance, or situation such as EKGs, ED and clinic visits, radiologyand laboratory services. To soft-code a service or item is to not include the HCPCS/CPT in the CDM.The service or item requires coding to be done manually by HIM or other means.Soft-coding is suitable for procedures that are variable in nature; such as surgicalprocedures (e.g. CPT codes 10000-69999). 9 10. CHARGE DESCRIPTION MASTERCurrent 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, withJanuary 1 effective dates for changes.Focus on Appendix B of the CPT Coding Manual Summary of Additions,Deletions, and Revisions when evaluating the necessary changes to thecharge master.CPT Code Categories:Evaluation and ManagementCPT Codes 99201 99499Anesthesia CPT Codes 00100 01999SurgeryCPT Codes 10021 69990RadiologyCPT Codes 70010 79999Pathology & Laboratory CPT Codes 80048 89399Medicine CPT Codes 90281 9919910 11. CHARGE DESCRIPTION MASTERHealthcare Common Procedure Coding System or HCPCS Codes (Level II)Maintained and revised throughout the year by CMS.New HCPCS codes are effective January 1 of each year, with quarterlyupdates.HCPCS Code Categories: A Codes Transportation servicesK Codes DME Regional Carriers B Codes Enteral and Parental Therapy L Codes Orthotic and Prosthetic Procedures C Codes Temporary codes for use with OPPSM Codes Other Medical Services D Codes Dental proceduresP Codes Pathology and Laboratory Services E Codes Durable Medical EquipmentQ Codes Temporary G CodesProcedures and Professional ServicesR Codes Diagnostic Radiology Services H CodesAlcohol & Drug Abuse Treatment Services S Codes Natl Codes (Non-Medicare) J CodesDrugs Administered Other Than OralT Codes Natl Codes for State Medicaid AgenciesV Codes Vision and Hearing Services 11 12. CHARGE DESCRIPTION MASTERCPT Category III CodesMaintained and updated semiannually by the AMA.Temporary codes for emerging technologies, services, andprocedures.Use Category III Code if available in lieu of Category I unlistedCPT Code.Codes have a alpha character as the fifth digit.Category Code III assignment does not imply coverage.12 13. CHARGE DESCRIPTION MASTERCPT and HCPCS Level II ModifiersModifiers provide a means by which a service can be alteredwithout changing the procedure code.Required by CMS to be reported for outpatient services.The CPT modifiers currently approved for hospital reportinginclude: 25, 27, 50, 52, 58, 59, 73, 74, 76, 77, 78, 79 and 91.The HCPCS modifiers that are currently approved for hospitalreporting are: CA, E1 through E4, FA through F9, BL, GN, GO,GP, GA, GY, GZ, GG, GH, LC, LD, RC, LT, RT, and TA through T9.13 14. CHARGE DESCRIPTION MASTERCPT and HCPCS Level II ModifiersVarying methods of modifier assignment:Hard coded in the charge masterAssigned by HIMAssigned during charge entry processAssigned through automated editsAssigned during pre-bill by PFSAssignment of correct modifiers can be critical toreimbursementModifier 25Modifier 50Modifier 59Modifier CA 14 15. CHARGE DESCRIPTION MASTERCPT and HCPCS Level II ModifiersMost common modifiers:25 Significant, separately identifiable evaluation and managementservice by the same physician on the same day of the procedure orother service.27 Multiple outpatient hospital E/M encounters on the same date50 Bilateral procedure52 Reduced services59 Distinct procedure91 Repeat clinical diagnostic laboratory testLT Left sideRT - Right side15 16. CHARGE DESCRIPTION MASTERHospital facilities also incorporate standard business rulesaround how their CDM is structured.Considerations can include the following: inclusion or use of statistical or other zero dollar line items Example: patient visit counters for productivity measures the determination of allowable items for charging Example: charging thresholds, routine supplies duplicate CPT codes across clinical departments Example: EKGs in the emergency department, clinics and diagnostic cardiology use of charge explosions use of miscellaneous CDMs decisions to standardize the CDM across a health system16 17. CHARGE DESCRIPTION MASTERThe CDM is one of the most complex master files within anyhospital facility and is subject to continuous updates.Proper maintenance is essential to ensure proper charging forservices and supplies within financial and regulatoryparameters.Poor maintenance of the CDM can put the hospital at financialrisk and may introduce risk of regulatory non-compliance.Because the Healthcare Common Procedure Coding System (HCPCS) codes andAPCs are updated regularly, hospitals should pay particular attention to the taskof updating the CDM to ensure the assignment of correct codes to outpatientclaims. This should include timely updates, proper use of modifiers, and correctassociations between procedure codes and revenue codes. - OIG Compliance Guidance for Hospitals 17 18. CHARGE DESCRIPTION MASTERScenario Hospital bills and is reimbursed for services performed outside of the hospital. The staff performing the se