Pennsylvania Workers’ Compensation CDM Updates

Presented by: Tim MoscoPrincipalSunStone Consulting, LLC(717) 469-0386TimMosco@sunstoneconsulting.com

February 18, 2010

• Formed in October of 2002

• SunStone’s core leadership has been together since the early 1990’s

• Client base ranges from large teaching institutions to children’s hospitals to small community hospitals and outpatient clinics

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Who is SunStone Consulting?

• Service offerings include:– Charge Description Master (CDM)– CDM Pricing– Inpatient & Outpatient Coding– RAC Assessments– Compliance– Pharmacy Revenue Cycle Consulting– Reimbursement & Financial Analysis– Revenue Cycle Consulting– Transfer DRG Reviews– Workers’ Compensation CDM & Consulting Services

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Who is SunStone Consulting?

• The CDM is one of the primary drivers of outpatient workers’ compensation payments

• There are various outpatient payment mechanisms:– The CDM -> This is the Bureau’s “Cost Allowance Table” and

accounts for over 50% of all line item outpatient payments.– Laboratory Fee Schedule -> Based on HCPCS codes and

accounts for about 13% of line item outpatient payments.– Frozen Pharmacy RCC -> This RCC is applied to any pharmacy

revenue code to determine payments and accounts for about 36% of all line item payments.

– Other mechanisms make up the difference (e.g., physician fee schedule, prosthetic/orthotic fee schedule, percentage of charges, line-item denials, etc).

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Why do CDM updates matter?

• March 1, 2010– Results mailed to insurers April 15, 2010

• June 1, 2010– Results mailed to insurers July 15, 2010

• September 1, 2010– Results mailed to insurers October 15, 2010

• December 1, 2010– Results mailed to insurers January 15, 2011

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2010 CDM Update Schedule

• Compare entire CDM to the Bureau’s file.– Identify any item that is on your CDM but is

not on the Bureau’s file by service code.• Note: Do not simply use your internal system date

– The specific CDM items that do not match should be flagged or a separate table created of all unmatched or “new” items.

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CDM Update Process

• Remove any items not eligible for submission. These items include the following revenue codes:– 25x – Drugs– 636 – Drugs– 30x – Clinical Lab– 33x – Chemotherapy– 28x – Oncology– 29x – DME– 510 – Clinic not related to W/C– 55x through 60x Home Health Services

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CDM Update Process

• Remove any items not eligible for submission. These items include the following revenue codes (continued):– 64x – Home IV Therapy Services– 65x – Hospice– 72x – Labor & Delivery– 77x – Preventative Care Services– 800 – Inpatient Renal Dialysis– 45x – Only applies to procedures not E&Ms– Professional fees

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CDM Update Process

• Assign the proper RCC to each “new” CDM item.

– Most hospitals RCCs will date back to the 1992 Medicare Cost Report.

– Assignment process must be consistent with the past methods.

• Usually revenue code or department number.

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CDM Update Process

• Perform crosswalking of “new” items to existing items on the Bureau’s file.

• The concept is to ensure that hospitals do not “game the system” to increase reimbursements.– Match first based on HCPCS codes.– Match on descriptions to the extent

possible.– Be sure to only link “new” to existing items

that are mapped to the same RCC.

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CDM Update Process

• Chose an implementation date.– Use the system date if it shows the date that the CDM

item became effective.– Estimate if no implementation date is available.– Can have an impact on payments so be careful.

• Assign an “Action” indicator code– A1 = All “new” items not crosswalked

– C2 = All “new” items crosswalked to an existing cost allowance table item

– Note that C1 (CDM field change) is not longer accepted as of 12/1/2008

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CDM Update Process

• Format the file exactly as specified by the Bureau.

Structure for table cmMar10.txt

-------------------------------------------------------Field Field Name Type Length 1 SERVICE_CD CHARACTER 25 2 HCPCS_CD CHARACTER 5 3 REVENUE_CD CHARACTER 3 4 DESCRIPT CHARACTER 40 5 IP_PRICE CHARACTER 8 6 OP_PRICE CHARACTER 8 7 IP_RCC CHARACTER 9 8 OP_RCC CHARACTER 9 9 IMPDATE CHARACTER 8 10 ACTION CHARACTER 2 11 XWALKSVSCD CHARACTER 25 -------------------------------------------------------

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CDM Update Process

• File naming convention

– cmMar10.txt

– cmJun10.txt

– cmSep10.txt

– cmDec10.txt

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CDM Update Process

• Create a disk label

Current Charge File Vol. 1 of 1

Provider Number: 39-xxxx EIN: 99-9999999

Provider Name: Hospital Name

Total Number of Records: 399

Sum Total of In-Patient Price: 244,336.05

Sum Total of Out-Patient Price: 244,336.05

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CDM Update Process

• Complete the Bureau’s “Exhibit A” – Charge Master Data Request– Hospital/Facility Name– Address– EIN– Old Medicare Provider Number– New NPI number– Primary and secondary (if applicable) CDM

contacts

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CDM Update Process

Questions & Comments

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CDM Update Process