Charge Description Master and Revenue Integrity: Putting the Pieces Together Presented by: Catherine (Kate) H. Clark, CPC, CRCE-I Vice President Maryland AAHAM, Past President

Objectives This presentation will define and promote understanding of the following: Charge Description Master (CDM) Defined Revenue Integrity Defined CDM Management Options Revenue Integrity, CDM, and the Revenue Cycle – How can we do it better?

Polling Question #1 Respond to what role you play in relationship to the CDM/Revenue Integrity for your current position. CDM Coordinator/Manager CFO/CIO/COO/CEO Revenue Cycle Staff Finance/Reimbursement Staff Contracting Care/Case Management/CDI/Denials Other

Why Now? Transition from Inpatient to Outpatient Outpatient visits doubled from 1990-2010 (50%) Inpatient admissions grew by 13% Outpatient charges impacted by charge capture (% of charges = Reimbursement) Charge Capture Matters Additional reimbursement Accurate calculation of costs Revenue Tracking by Department Maryland – Global Budget through HSCRC Non-Maryland – Ambulatory Payment Classifications (APCs) Transition to Meaningful Use, Patient Experience, and Quality Measures -

Why Now? Electronic Medical Records (EMR) Timing and Resources Cleaning Up before EMR is built Preparation = Less Clean-up Crosswalk of a “constant” current state to EMR build Departments are responsible for Reconciliation (Revenue Integrity?) Timing and Resources January, October Contracting updates for Non-Medicare payers Updated Coding Guidelines APC and HSCRC Updates

Polling Question #2 In your opinion, what is the most important function of the CDM? Charge Capture Compliance Denials Management Medical Necessity Verification Point of Service Collections Accurate Claim Submission None of the Above All of the Above

Source: http://en.wikipedia.org/wiki/Chargemaster CDM Defined Charge Description Master (CDM) A comprehensive listing of items billable to a hospital patient or patient’s health insurance provider. Master file built within the hospital information systems which is designed to interface with other software applications to support billing and reporting. Fields include (but are not limited to): Revenue codes Current Procedural Terminology (CPT) or HealthCare Procedural Coding System (HCPCS) Pricing Service descriptions Relative Value Units (RVUs) when applicable Payer Specific Data Elements Source: http://en.wikipedia.org/wiki/Chargemaster

CDM Defined CDM and the Claim Form Has been described as “the central mechanism of the revenue cycle” of a hospital. The CDM is closely linked to revenue generation. It is fundamental to the charge capture process. Many CDMs are now being used as a component of revenue integrity validation. CDM populates the claim form based on documented parameters, by payer, which decreases the number of “manual touches” by Patient Financial Services (PFS) staff.

Revenue Integrity Defined Purpose: to prevent recurrence of issues that can cause revenue leakage and/or compliance risk. • Revenue Integrity focuses on process improvements • Revenue Integrity provides a check/balance system for the revenue cycle components, with support from leadership and technology. Revenue Integrity Stand-alone Department Corporate Initiative Organizational Structure

Components of CDM/Revenue Integrity CPT/HCPCS Units of Service Rates/Pricing Knowledge: Billing & Clinical Charge Master Reimbursement PPS & Fee Schedules Supply Chain & Pharmacy Mgmt General Ledger Complete & Correct Information = Paid Claims

CDM Management Options Components to Consider Risk Relationships Compliance CDM Team Meeting Attendance – enforced by leadership Mandatory Composition of the Team Who participates CDM Team Titles and Roles CDM Staff Translator-Explanation of Roles Manager Coordinator Analyst Finance Staff

CDM Management Options Characteristics of effective CDM staff Detail oriented Inquisitive Relentless Highly organized “Even” disposition Good written and verbal communication skills Quick

CDM Management Options – Set-Up New Line Item Creation Clinical HIM Rates and Reimbursement Contracting PFS Financial Counseling/Patient Access Sign-Off of New Line Item by Impacted Areas Are services provided billable? Do they translate to CDM line items? Each Department to sign-off (see above) must contribute with their piece of the puzzle

CDM Management Options Enterprise vs. Single-Entity CDM Management Size of CDM Order Entry mapping to correct CDM lines Problematic for both entities, but moreso for Enterprise CDM Fee Schedule Management within CDM Updates Multiple facility or enterprise builds with dedicated staff vs. single entity staff who are responsible for multiple roles. Electronic Health Record – controlled by whom Are providers Regulated and Non-Regulated

CDM Management Options Internal vs. External CDM Management Options Review goals of the CDM for organization Cost of Vendor vs. Cost of Resources Coordination of Information – NCD, LCD, Contracts Implementation of changes Communication with clinical staff Information Technology interfaces Data validation Which option saves time or are more valuable?

Revenue Integrity and Revenue Cycle CHARGE CAPTURE MD ORDER ENTRY SCHED & REG ORDER ENTRY BILLING PAYER TABLE CPT CODE REV CODE PRICING RVU HIM CPT CODES BILLING ============PAYMENT=============PFS

Revenue Integrity, CDM, & Revenue Cycle CDM = Cash Flow Updated CDM leads to faster cash Scheduling Clinical tests are scheduled based on CPT Codes Patient balances calculated at time of scheduled procedure Advanced Beneficiary Notice (ABN) Software ABN executed based on CPT code assigned to test. CPT is determined by CDM Estimate patient balances if service is non-covered (All non-covered services do not require an ABN) Pre-Authorization Services are pre-authorized with insurance companies based on the CPT code of the service. Point of care collections – based on CDM pricing

Revenue Integrity, CDM, & Revenue Cycle Charge Capture – Electronic or Manual Electronic = Interface of charges through systems Manual = Direct data entry into billing module Both require accurate CDM set-up Preference List (clinical charges) to CDM Charge Entry from Clinical Staff or Charge Staff Set-up must be determined before Preference list build Order Entry Systems – Pyxis, Lab, Radiology, MUSE Charge triggered based on parameters Parameters defined by medical center, facility, or provider Typically requires physician signature, physician order, or nursing entry

Revenue Integrity, CDM, & Revenue Cycle Charge Capture – Electronic or Manual Electronic Health Record (EHR) documentation Automatic generation of charges through completed documentation Encounter Forms Completed by provider of care or designee Manual entry into billing system Typically direct data entry into billing system Professional Fees Triggered from Facility CDM Professional Provider CDM

Revenue Integrity, CDM, & Revenue Cycle UB-04 Claim Form Billing of services performed to payers Interface to billing systems or claim scrubber software Bridge Routines – what is built behind the scenes for claim correction in order for them to be submitted to payers as “clean” claims. Payer Tables Compare patient insurance to payer information tables within the CDM to ensure accurate revenue and CPT/HCPCS information on the claim form.

Revenue Integrity, CDM, & Revenue Cycle Health Services Cost Review Commission (HSCRC) (Maryland Hospitals Only) HSCRC components are contained within the CDM as RVUs or prices for drugs and supplies Rate compliance within each Department reported to the HSCRC Outpatient Prospective Payment System (OPPS) Pricing of services based on reimbursement Bundled services – still built separately in the CDM as needed Outlier Payments Denials Management/Cash Posting Communication of payer needs through denials and interface back to CDM Denied services are communicated to the provider of care using specific HIPAA compliant denial codes. Ongoing denial activity on specific line items must be communicated back to the CDM Team. Correct Coding Initiative (CCI) Edits

Revenue Integrity, CDM, & Revenue Cycle Health Information Management (HIM) HIM coding of services within the hospital No linkage to a specific CDM populated with CPT/HCPCS HIM coded CPT/HCPCS codes must map to the appropriate revenue codes, which are identified in the CDM. CDM mapping to specific revenue codes allows HIM coded services to cross to the claim form Clinical Staff Clinicians and Clinical Leadership must be involved with the set-up and maintenance of the CDM. Denied services are communicated to the provider of care using specific HIPAA compliant denial codes. Compliance Each CDM that includes CPT/HCPCS, price, and quantity is subject to evaluation for compliance with billing and coding rules. Correct Coding Initiative (CCI) Edits Payer Edits

INSURANCE VERIFICATION PROGRAM ADMINISTRATION CDM and Revenue Cycle SCHEDULING POST PAYMENT REVIEW REGISTRATION EXPECTATIONS CUSTOMER REGULATIONS INSURANCE VERIFICATION CASH POSTING PROGRAM ADMINISTRATION POINT OF SERVICE COLLECTIONS SELF PAY COLLECTIONS FINANCIAL CLEARANCE CULTURE PEOPLE CUSTOMER SERVICE FINANCIAL COUNSELING PROCESS TOOLS THIRD PARTY FOLLOW- UP DENIALS MANAGEMENT CASE MGMT/QUR BILLING TECHNOLOGY PAYORS COMPLIANCE CDM/CHARGE CAPTURE MEDICAL RECORDS Dependent Related Adapted from -Source: http://healthdatamanagement.com/media/RC101

Revenue Integrity within Revenue Cycle What is it… How is it different from Charge Capture (only) How is it measured? What tools are used? How does current workflow or culture impact revenue integrity? How do we know it is right? Accountability Oversight Maintenance

CDM and Revenue Integrity Key Strategies • Create staff awareness • Provide tools and/or guidance • Design and implement a process for monitoring • Development of tools • Analysis of results to identify root causes • Develop corrective action plans • Track corrective action plan implementation • Verify improvement • Maintain oversight • Reporting to leadership.

Polling Question #3 Has your facility performed a comprehensive CDM review within the past year? Yes, completed using internal resources Yes, using an outside firm Yes, using both internal resources and outside firm No, not within the past year I Do Not Know

CDM and Revenue Integrity - Strategies When are CPT Codes and CDMs Updated Is there a schedule for general CDM Updates Outreach to clinical areas Outreach to PFS Baseline validation of the CDM by external company HSCRC review of RVUs for CDM validation Review of each clinical area ensuring the CDM is accurate Ensure Operational workflow is supported by accurate CDM set-up Crosswalks between systems must be up-to-date and accurate (current file maintenance reduces interface errors and manual corrections) EHR mapping of charges Interface with HIM Order Entry mapping to the CDM Preference Lists mapping to CDM Charge Documents – including professional fee (in hospital setting)

CDM and Revenue Integrity Strategies Communication Scheduling, Registration, Pre-authorization Physicians, clinicians, or other providers Patient Financial Services (PFS) – Facility and Professional HIM, Denials, Nurse Auditors, CDI, Care/Case Management Comprehensive CDM Review Discussion Education Who teaches and relays the material Who receives and is being trained on the material What are the details of what is taught How do you know the information is accurate

CDM, Revenue Integrity, and You What can you do… Understand the chain of command Gather Facts – Reports, examples, data, results of queries Communication – Not Personal, Direct, Focused Ownership of Findings Follow-Up Follow- Up (x2) if Issue Not Closed Doing the Work vs. Doing it Well

Final Comments Reimbursement Methodology Does not change the need for a compliant and current CDM and Revenue Integrity Plan. Updating the CDM Policies and procedures Code updates (at least 1x per year) Inactivating or Added Services Compliance Plan Once a CDM policy and procedure is documented (frequency of review, how new line items are created, consolidating the CDM), it must be followed. Revenue Integrity directly ties to compliance Comment in Closing: Stay current or you will never catch up

Questions Thank You! Catherine (Kate) Clark, CPC, CRCE-I Vice President Past President, Maryland AAHAM cclark@kohlerhc.com (410) 979-1624 Kohler HealthCare Consulting, Inc. www.kohlerhealthcareconsulting.com (410) 461-5116 – Office