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Pennsylvania Workers’ Compensation CDM Updates Presented by: Tim Mosco Principal

Pennsylvania Workers’ Compensation CDM Updates Presented by: Tim Mosco Principal SunStone Consulting, LLC (717) 469-0386 TimMosco@sunstoneconsulting.com February 18, 2010. Who is SunStone Consulting?. Formed in October of 2002

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Pennsylvania Workers’ Compensation CDM Updates Presented by: Tim Mosco Principal

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  1. Pennsylvania Workers’ Compensation CDM Updates Presented by: Tim Mosco Principal SunStone Consulting, LLC (717) 469-0386 TimMosco@sunstoneconsulting.com February 18, 2010

  2. Who is SunStone Consulting? • 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 2

  3. 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 3

  4. Why do CDM updates matter? • 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). 4

  5. 2010 CDM Update Schedule • 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 5

  6. CDM Update Process • 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. 6

  7. 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 7

  8. 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 8

  9. 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. 9

  10. 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. 10

  11. 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 11

  12. 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 ------------------------------------------------------- 12

  13. CDM Update Process • File naming convention • cmMar10.txt • cmJun10.txt • cmSep10.txt • cmDec10.txt 13

  14. 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 14

  15. 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 15

  16. CDM Update Process Questions & Comments 16

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