1 Best Practices in Charge Capture Hosted by Craneware December 15, 2008 Presenters: Angela Confoey, Kathy Lytal, Denise Foley and Jonnetta Selvidge

2 Disclaimer  This presentation is designed to provide accurate and authoritative information. The author, presenter and sponsors have made every reasonable effort to ensure the accuracy of the information provided in this session. However, all appropriate sources should be verified for the correct use of HCPCS Level I, II & III codes, Modifiers, and Revenue Center Codes. The user is ultimately responsible for correct coding and billing.  The author and presenter is not liable and makes no guarantee, either expressed or implied, that the information compiled or presented is error free. All users need to verify information with their Fiscal Intermediary, Carriers, other third party payers, and the various directives and memorandums issued by CMS and other associated state and federal government agencies. The user assumes all risk and liability with the use and/or misuse of this information.  CPT/HCPCS codes, descriptions and material only are copyright of the AMA.  Other copyrighted material has been used with the permission of the author/publisher and any additional use of this copyrighted material must have the consent of the author/publisher.

3 Panel question: What triggered your organization to review your charge capture process

4 Charge Capture: A Multiple Step Approach December 15, 2008 Angela Confoey, Corporate Director CDM Caritas Christi Health Care System

5  Second Largest Health System in New England  Acute care hospitals: 6  Annual inpatient discharges: 73,546  Annual ED visits: 238,551  HIS System: Meditech Client/Server

6 Caritas: CDM Standardization Project Scope:  Establish a corporate standard CDM across all six hospitals  Ensure that the CDM file is inclusive of all billable services provided by the hospital and contains valid codes that accurately reflect the services delivered  Identify additional financial opportunities  Rollout of CDM maintenance process

7 Caritas: CDM Standardization Results:  $1.6 million annualized additional net revenue  Added 797 new procedure charges to the CDM, where departments were not charging for a particular service  Provided the ability to compare CDM for service lines across facilities and ensure completeness and accuracy  Enhanced communication between clinical departments, Finance, IS, PFS, and HIM

8 Caritas: Claim Audit/ Charge Capture Review Purpose:  A review of two months of Caritas Christi outpatient claims in order to identify missing revenue opportunities Findings:  Approximately $1M in Net Revenue  Common issues across the system included drug administration, cardiac catheterization, and missing device codes

9 Caritas: Claim Audit/ Charge Capture Review Root Cause Breakdown  21% Coding – Staff Education Needed (Cardiology & Drug Administration)  74% Charge Capture – Daily Reconciliation Process Needed  3% CDM – Device C- codes Missing  2% Other

10 Caritas: Charge Rejections/Daily Reconciliation  Charge Rejections occur when charges input into the charge entry modules do not post into the billing system  From August to December 2007 Caritas had 899 charge rejections, a total of $960,838 in gross revenue, across the system

11 Caritas: Charge Rejections/Daily Reconciliation Approach:  Developed tools for monitoring charge rejections and performing daily reconciliation  Audited charge entry modules against CDM  Defined accountability in clinical departments  Communicated the initiative to staff as a top priority from Senior Leadership  Scheduled and performed mandatory staff training sessions

12 Caritas: Tools for Monitoring and Working Charge Rejections

13 Caritas: Daily Reconciliation Reports

14 Pharmacy Charge Capture Process Improvement December 15, 2008 Kathy Lytal, Revenue Manager Parkview Health

15 Parkview Health  Eight Hospital Integrated Delivery Network in Northeast Indiana  Standard Clinical & Financial IT Platforms  Corporate Pharmacy Management Model  Concurrent Pharmacy Medical Chart Audits  Inpatient and Observation

16 Parkview: Pharmacy Competing Priorities  Clinical Focus  Patient Medication Safety  Patient Quality  Physician Satisfaction  Regulatory Compliance  DEA, JCAHO, Board of Health  Managing Inventories and Drug Costs  Staff Recruitment and Retention  Revenue Cycle

17 Parkview: Pharmacy Revenue Cycle  Inpatient  Ambulatory  Clinics Infusion Therapy High Tech Injections  ED and Outpatient Surgery Services

18 Parkview: Pharmacy Revenue Cycle  Charge Capture Methodology within IT Infrastructure  Point of Drug Administration  Point of Drug Dispense  Correct Coding and Units Reporting  HCPCS, NDC, and Revenue Codes  Billable Units  Effective Internal Controls

19 Parkview: Validation  Volume Reconciliation  Purchase History vs. Charge Utilization  Completeness  Purchase History vs. Drug Master Management of Non-Formulary Products

20 Parkview: Continuous Process Improvement  Leverage Technology to Support Exception Reporting  Validation  Root Cause Analysis  Action Plan  Continuous Monitoring

21 QUESTIONS???

22 Infusions and Injections Charge Capture December 15, 2008 Denise Foley, Director, CDM Catholic Health East

23 CHE Overview  CATHOLIC HEALTH EAST (CHE) is a multi-institutional Catholic health system with hospitals located within 11 eastern states from Maine to Florida  Corporate CDM - 18 hospitals  HIS Systems – Meditech Client Server, Meditech Magic and Siemens

24 CHE: CDM Standardization Project  Objectives:  Corporate CDM – Centralized & Standardized Cross facility comparisons Automate CDM maintenance Transform departments from CDM maintenance to revenue enhancement

25 CHE: Project Phases  Build corporate CDM  Implement charge capture assessment tools  To help improve 2008 operating performance and cash flow  To identify charge capture process issues Infusions & injections  To ensure expense to revenue correlation  Build revenue teams  Continuous improvement process

26 CHE: Infusion Confusion  Infusions & injections were an organization wide challenge.  Loss of revenue due to:  Charging add on codes without parent codes  Hierarchy confusion – hydration vs. drugs  Inconsistent Start & stop times

27 CHE: Improvement Approach  Education, continuous assessment & best practice documentation  Education from infusion/injection coding expert  Early re-education for 2009 changes  Assess documentation practices & form layout  Best practices Color coded infusion charge capture guide Compile standardized charge sheet

28 CHE: How Do we Measure Success?  Continuous & automated monitoring via software tools  95% reduction in identified issues  Discernible revenue & usage statistics increase  Reduction in services denied

29 CHE: Final Thoughts  Always new employees in the process  Codes will continue to change  Make sure CDMs & encounter forms/charge tickets are up to date  Review documentation practices  Education  Tools for automation are necessary

30 Surgical Implant Charge Capture December 15, 2008 Jonnetta Selvidge, Director, Revenue Integrity St. John Health System

31 St. John Health System  One of the largest health systems in Oklahoma  Includes acute care hospitals, physician practices, occupational medicine clinics, senior living centers, and outpatient facilities  The health system contains > 800 hospital beds  Annual ER visits: > 128,000  Annual surgeries: > 27,000  Neurosurgical and orthopedic cases comprise more than 25% of annual surgical volume  Caring for > 3,000 patients every day

32 St. John: Surgical and Implant Charge Capture & Coding  Getting started – Step One  Descriptions on the bill were very generic.  On review of the patient record: Some items on the chart didn’t appear on the bill Some items on the bill didn’t appear on the patient’s record, and The items that did match, the number of units didn’t match.  Out of desperation, the vendor was contacted who then faxed a copy of the purchase order for that particular case to SJMC.

33 St. John: Surgical and Implant Charge Capture & Coding  Understanding the depth of the problem – Step Two  Upon correcting the one bill with an addition of approximately $4,500 in charges, a review of the last 25 cases that had implants was performed. Upon discovering the severity of billing inaccuracies, the chart/bill review was expanded to include all orthopedic and neuro surgical implant cases which resulted in over $1 million in additional charges over an eight week implant period.

34 St. John: Surgical and Implant Charge Capture & Coding  Long Term Solutions – Step Three  Involved surgical-clerical team as well as the Business Office and CDM staff  Developed new procedures, documentation, and verification processes. Use data mining tools and techniques to limit manual reviews  Continue to evaluate and update processes as needs arise.

35 St. John: Surgical and Implant Charge Capture & Coding  Charge Description Master (CDM) * Cost above does not reflect actual manufacturer pricing

36 St. John: Implant Purchase Order * Cost above does not reflect actual manufacturer pricing

37 St. John: Setting Device Charges Chargemaster Impact  Medicare represents % hospital’s revenue  Most reimbursement calculations are based on the Medicare model  Future reimbursement is determined by what is being billed today  Most APC payment calculations were based on historical billing data  APC payments are not really as high as they should be  Your Current Reimbursement depends on you having an accurate Chargemaster today…and everyday

38 St. John: Setting Device Charges to Recoup Costs  C Code Mark-up - To ensure that future updates of the device codes accurately reflect the cost of the device, the mark up should be such that actual cost is calculated by CMS when they apply the OPPS cost-to-charge ratio Description MDT AICD Rev Code 275 CPT Code C1882 Cost $24, Charge $61, Charge$61, CCRx Reimbursed $22,646.14

39 St. John: Charge Capture & Coding Requires Systematic Approach  Charge Capture and Coding – everyone needs to be involved  Communication is the key to success  Education, education, education Clerical staff, Clinical staff, Technical staff & Physicians  Important to keep everyone in the information loop  Add CDM & internal audits to QA or QI agenda  Periodically check for “leaks” in your system  CDM Review should be done regularly

40 QUESTIONS???

41 Panel question: What are the your next steps in maintaining your charge capture process?

42 QUESTIONS???

43 Thank You Angela Confoey – Caritas Christi Kathy Lytal – Parkview Health Denise Foley – Catholic Health East Jonnetta Selvidge – St. John Health System For additional information contact Craneware: