lisa poworoznek director, budget & reimbursement finger lakes health may 22, 2014
TRANSCRIPT
Lisa PoworoznekDirector, Budget & ReimbursementFinger Lakes Health May 22, 2014
Charge Code
Charge Amount
Exploding Rules
RVU
Modifiers
CPT/HCPCS
Department #
Multipliers
Description
Revenue Code
Adds additional procedure explanation
One charge code for two procedures always performed together
Relative Value Unit
General ledger department service performed within
“Patient Friendly” description
Facility assigned mnemonic, unique to one service
Pharmacy option – matches order to code
Procedural Coding Systems: CPT – AMA HCPCS – CMS CPT = Current Procedural Terminology HCPCS = Healthcare Common
procedure Coding System
3 digit code categorizing the service: National Uniform Billing Committee
Financial fee assigned to line item
*Exhibit 51 - ICRPROVIDER NO. XX-XXXX NEW YORK STATE DEPARTMENT OF HEALTH VERSION: 2013.01PERIOD FROM 01/01/2012 TO 12/31/2012 INSTITUTIONAL COST REPORT 05/31/2013 08:17:05RATIO OF COST TO CHARGES - OUTPATIENT CHARGE MAPPING (REVENUE CODES) - PART III EXHIBIT 51
COST COST COST COST COSTCENTER REVENUE CENTER REVENUE CENTER REVENUE CENTER REVENUE CENTER REVENUEGROUP CODE GROUP CODE GROUP CODE GROUP CODE GROUP CODE45020 45020 45020 45020 45020 39 987 19 986 20 985 89 982 21 981 72 976 17 972 33 971 47 964 21 961 56 960 55 943 85 942 47 941 47 940 72 921 56 920 21 900 30 851 30 845 30 841 30 804 30 803 30 801 61 771 39 762 47 761 47 750 89 740 20 732 20 731 20 730 15 729 15 720 47 710 47 700 61 637 61 636 41 622 41 621 36 618 36 615 36 612 36 611 36 610 76 559 56 510 56 509 47 490 20 483 20 482 20 481 20 480 78 471 43 470 72 460 21 450 78 444 78 443 78 441 78 440 45 434 45 431 45 430 62 424 62 421 62 420 72 419 72 410 17 403 17 402 17 401 09 391 09 390 47 370 47 369 47 362 17 361 47 360 11 359 11 352 11 351 11 350 44 343 44 341 30 335 30 331 17 324 17 323 17 322 17 320 33 319 33 312 33 311 33 310 33 309 33 307 33 306 33 305 33 302 33 301 33 300 41 278 41 276 41 275 41 272 41 270 61 264 47 260 61 259 17 255 61 252 61 251 61 250 40 200 43 171 39 141 70 128 39 122 39 121 76 120 70 118 39 116 39 111 76 110
*MAC – Medicare Administrative Contractors*CERT – Comprehensive Error Rate Testing Contractors*ZPIC – Zone Program Integrity Contractors*SMRC – Supplemental Medical Review Contractors*Commercial Payors*OIG – Office of Inspector General*DOJ – Department of Justice*OMIG – Office of Medicaid Inspector General*MIP – Medicaid Integrity Plan*Self Pay Patients*Media*Watch Groups
The U.S. Department of Health and Human Services is releasing the "chargemaster" price list of the 100 most common inpatient procedures for all U.S. hospitals, inspired by Time's March 4 expose on hidden medical billing.
“The second reason the compilation and release of this data is a big deal is that it demonstrates the point I tried to make in spotlighting the seven sample medical bills in Time’s “Bitter Pill” report: most hospitals’ chargemaster prices are wildly inconsistent and seem to have no rationale. Thus the release of this fire hose of data—which prints out at 17,511 pages—should become a tip sheet for reporters in every American city and town, who can now ask hospitals to explain their pricing.”
*The Affordable Care Act (ACA) requires that hospitals "for each year establish (and update) and make public (in accordance with guidelines developed by the [Health and Human Services] Secretary) a list of the hospital's standard charges for items and services provided by the hospital, including for diagnosis-related groups established under Section 1886(d)(4) of the Social Security Act.“
*Until now, CMS has not issued the required guidelines. In the rule, CMS is "reminding hospitals of their obligation to comply" with this requirement. CMS states that its guidelines are "that hospitals either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or their policies for allowing the public to view a list of those charges in response to an inquiry." CMS does not provide a deadline for compliance, but expects that hospitals will update the information at least annually, or more often as appropriate, to reflect current charges.
May 1, 2014
Medicare IPPS Proposed Rule Includes Significant Payment Changes for FFY 2015
Chargemaster
*Recommends Action to Avoid Compliance Concerns
*Directs Chargemaster Review Team in Ongoing Refinements
*Liaison between Finance and Clinical
*Develop Policies and Procedures
*Maintance – Qtrly CMS, Monthly Bulletins
*Evaluate Additional Charge Capture Possibilities
*Keeping Abreast of New Coding Regulations
*Assess Contractual Issues for Impacts
*Education Opportunities
*Evaluate Current Charge with Active Listening
*Charge Forms/Tickets – Process Review
*Partner with Billing to Assist and Ensure “Clean Claims”
Blood Transfusion Administration
Injection Administration
IV Push Administration
Patient Education
Medical/Surgical SuppliesBedside Procedures, i.e.. Wound Vac, Pressure UlcersTransportation: Ambulance & Nursing Oversight
Specialized Room Rates
*Medicare Guidelines state routine supply charges will be bundled into the procedure, room rate or leveling system.
- Routine Items: Gowns, Gloves masks, Blood Pressure Cuffs, Ice Bags, IV Tubing, Pillows, Towels, Thermometers, Wash Clothes, Soaps, Bed Linen, Diapers, Tourniquet, Gauze, Band Aids, Oxygen Masks, Syringes, Wall Suction, Drapes, Cotton Balls, Marking Pens, Pads, Urinals, Wipes, Toothbrushes, Shaving Kits, Chucks, Shampoo, Etc……
Is this for a specific patient?
Is medical necessity properly documented?
Is there a Physician order: Written, Verbal or Implied?
Is the item reusable?
What category does this fall into?
Unique Item or
ordered off shifts
Procedure Tray/Kit
Set Up Tray/Kit
Low Cost
Implant
Take Home
Non, Billable, Item is Routine
Non Billable, Bundled into
room/procedure
Non Billable, Personal
Non billable Without
If needed to
facilitate discharge
Track Independent
ly for ICR
Decide threshold – Bundle
Preparation kits are
not chargeabl
e
Review each item in kit: C-
codes
Communication
No
Yes
No
No
Emergency Department Charges TECHNICAL CHARGES
December 2013 YTD Stats
2013 2013 2013 UNIT EXTENDED MCR BLUES Mark Up RECOMMENDDEPT. MNEM. PROCEDURE QTY CHARGE TTL CHRGS CPT REV SI RVU MU COST COST REIMB REIMB to MCR CHARGE**3001 30010014 CUTDOWN >1YR VENIPUNCT 1 $40 $40 36425 450 X 0.3042 $14.00 $14 $20.47 $24.00 3.4 $70.00**3001 30010015 ARTERIAL PUNCTURE 6 $50 $300 36600 450 Q3 0.3042 1.00 $14.00 $84 $20.47 $30.00 3.4 $70.00**3001 30010016 INTRAOSSEOUS NEEDLE IN 9 $450 $4,050 36680 450 X 0.7353 1.22 $33.84 $305 $49.48 $270.00 3.4 $169.20**3001 30010034 REMOVE FB EAR 5 $140 $700 69200 450 X 0.7353 1.00 $33.84 $169 $49.48 $84.00 3.4 $169.20**3001 30010035 REMOVE CERUMEN 8 $14 $112 69210 450 X 0.7353 1.00 $33.84 $271 $49.48 $8.40 3.4 $169.20**3001 30100001 SUTURE REMOVAL 89 $180 $16,020 99281 450 V 0.7658 1.04 $35.24 $3,137 $51.53 $108.00 3.4 $176.22**3001 30010001 ED VISIT LEVEL 1 82 $180 $14,760 99281 450 V 0.7658 1.00 $35.24 $2,890 $51.53 $108.00 3.6 $183.00**3001 30010094 HAND STRAPPING 1 $190 $190 29280 450 S 0.7685 1.00 $35.37 $35 $51.71 $114.00 3.4 $176.84**3001 30010091 APPLY FINGER SPLINT 29 $169 $4,901 29130 450 S 0.7685 1.00 $35.37 $1,026 $51.71 $101.40 3.4 $176.84**3001 30010085 EVAL SUBUNGAL 1 $84 $84 11740 450 T 0.8370 1.09 $38.52 $39 $56.32 $50.40 3.4 $192.60**3001 30010039 REMOVE CORNEAL FB W SL 2 $271 $542 65222 450 S 1.0663 1.27 $49.07 $98 $71.75 $162.60 3.4 $245.37**3001 30010036 REMOVE FB EYE-SUPERFIC 2 $271 $542 65205 450 S 1.0663 1.00 $49.07 $98 $71.75 $162.60 3.4 $245.37**3001 30010038 REMOVE CORNEAL FB 1 $271 $271 65220 450 S 1.0663 1.00 $49.07 $49 $71.75 $162.60 3.4 $245.37
Marke
tSelf
PayCharity care
Competition
% of
Charge
Payors
Relationship to Cost
*Hard Coding: For procedures performed the exact same way on every patient. Applied by clinical personal performing the procedure. 70,000 – 90,000 codes Assumes documentation is present to support code
*Soft Coding: Medical record reviewed by coder and a procedure code is applied from documentation – Mainly used with surgical codes 10,000 – 60,000
*Collision Coding- Clinical applies hard code while HIM also soft codes, results in duplicate charges. Watch for these situations.
- Encourages staff to perform and/or “check off” services that are not required in order to validate productivity
- Additional maintenance as line items grow
- Charge for services without medical necessity
- No substantiating documentation
- Stat definition varies from revenue definition
Chargemaster
