2011 CDM Updates Day 1
Post on 19-Dec-2014
DESCRIPTIONPart 1 of 2 day workshop presented to the Western New York chapter of HFMA.
- 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 services did not indicate the patient location or type of service to charge entry staff. Similar services are provided within the hospital therefore billing staff do not question claims. The services are billed as if they were performed within the hospital walls. The hospital is reimbursed at a higher rate and benefit than would have been if the services were billed appropriately.Cause De-centralized CDM maintenance processes. Lack of charge capture knowledge within clinical department. Lack of participation of CDM Team in creation of new service line. Lack of regular CDM audit process.Consequences The hospital is fined over $1 million and is placed under a corporate integrity agreement with the OIG for 5 years. Required training and annual external review cost the hospital hundreds of thousands of dollars that are exempt from cost reporting. New positions are created and better controls in place as required under agreement. 18 19. CHARGE DESCRIPTION MASTERHospitals can benefit from a formal process that routinely seeksto improve the maintenance and management of the CDM.Management of the CDM requires a coordinated team effortled by a senior manager (CDM Coordinator).CDM Coordinators create the need for a specific skill set: knowledge of the clinical terminology understanding of the various procedures performed in a given specialty area a solid understanding of coding and billing functions ability to work with stakeholders of the front, middle and back end of the revenue cycle19 20. CHARGE DESCRIPTION MASTEREffective and efficient operation of the CDM requires closecoordination and participation by various departments. Patient Financial Services Financial Reimbursement and Contract Management Patient Care Departments Compliance and Revenue Integrity Health Information Management Information Systems= CDM TEAM20 21. CHARGE DESCRIPTION MASTERThe primary purpose of the CDM team is to review the CDMpolicies and procedures and to improve the management andunderstanding of the CDM across the hospital users.The team should review all the new items and services itintends to add to the CDM.The team should be able to suggest changes to existing CDMitems.CDM additions, revisions and deletions should be inventoriedthrough the use of a change request form.The purpose of the form is to help the team evaluate thechange request. 21 22. CHARGE DESCRIPTION MASTER22 23. CHARGE DESCRIPTION MASTERThe CDM team should establish a charge-audit process toensure that all new charges and planned changes to existingcharges are properly captured, reported, and documented. The focus of this audit is to examine not only the accuracy of the billing statement but also the supporting medical record documentation to prevent the charge from being denied.The CDM policies and procedures should also include aschedule for performing routine audits of the CDM. Limited reviews are recommended at least annually, with comprehensive reviews at a three-year interval.23 24. CHARGE DESCRIPTION MASTER Limited CDM ComprehensiveReview StepReviewCDM Review Review CDM for Deleted Codes Review CDM for Accurate Assignment in HCPCS/CPT, based on CDM Procedure or Service Description Review CDM for Accuracy in UB04 Revenue Code Assignment Review CDM for Accuracy in Unit of Service/Multiplier Assignment Review CDM for Missing HCPCS/CPT Review CDM for Zero Usage Line Items Review CDM Pricing Review CDM for Duplicate HCPCS/CPTs Review CDM Line Item Usage Against Expected Usage Patterns Review Departmental CDM, Charge Capture and Documentation Practices including review of charge capture tools and medical record documentation to charge capture Review Clinical Subsystem to CDM Linkage (aka Order Entry Mapping) 24 25. CHARGE DESCRIPTION MASTERThe CDM is a critical piece of effective revenue management.Hospital organizations of all sizes and capabilities are usingtools to support daily CDM maintenance. NOTE: this is a tool and not a complete solutionOptimal software packages include the following: online reference tools have a complete and active code book feature include a browser-based, cross-reference toolkit have the ability to analyze prospective and retrospective claims for potential charge capture and/or compliance issues25 26. OUTPATIENT REIMBURSEMENTWith the implementation of APCs in 2000, the CDM has had amore important role in the charge capture, coding and billingprocesses of services rendered.Payment is defined by the HCPCS/CPT codes reported, which inmany cases is hard-coded in the CDM.The importance of capturing and reporting the correctHCPCS/CPTs continues as Medicaid contractors, such as NewYork State Medicaid, adopt other reimbursementmethodologies such as Ambulatory Payment Groups (APGs) andas health care reform moves to bundled paymentmethodologies.26 27. OUTPATIENT REIMBURSEMENTAPC system was implemented by Medicare in 2000.Annual and quarterly update process.Payment for services is calculated based on APCgrouping logic.Services within an APC are simila...