Strategies for Revenue Cycle Management Focusing on the Charge Description Master Module Three Emergency Services
Emergency Room • Generally two types of services: • True Emergency Services • Non-emergency Services • Physician Office level • Scheduled services • Procedures
Medicare Payment Methods • Medicare • APC Hospital • Paid based upon CPT code assigned • CAH • Paid based upon cost of providing service as calculated in the annual cost report • Since costs are calculated using reported charges, if a service is not charged appropriately, the hospital will not receive proper payment.
Medicaid Payment Methods • Medicaid Emergency • APC Hospital and CAH • Paid based upon CMO contract or, • Paid based upon cost per cost report* • Medicaid Non-Emergency • APC Hospital and CAH • Paid based upon a fixed $ amount ($50) or • Paid based upon CMO contract *Since costs are calculated using reported charges, if a service is not charged, hospital will not receive payment.
What level to charge? • How do you determine what level to charge an emergency room patient? • APC Hospitals – specific CPT codes must be used (99281 – 99292) • CAH – specific CPT codes are not required; however it is advisable to use these codes
How are codes selected? • CMS’ guidelines specifically indicate that the visit (code) level should be determined by resource consumption that is not otherwise separately payable. • Examples: Nursing time, not separately billable supplies & drugs • Hospitals must maintain accurate documentation to support the resource consumption used.
Mapping Sheet • CMS guidelines require APC hospitals to utilize “mapping sheets” to document the resources used in assigning the level of the ER visit. • Although not specifically required, CAHs are encouraged to use a “mapping sheet” in determining the level of ER visit also.
Mapping Sheets • CMS has not provided hospitals with a standard or national “mapping sheet”. • CMS instructions are that the “mapping sheet” developed by the hospital must be uniformly used for all patients entering the ER, regardless of payer.
Mapping Sheet • The mapping sheet should not give “points” for procedures or services that are separately charged and paid in addition to the ER visit. • X-rays • Lab work • EKGs • However these procedures may serve as a reference to provide information as to the relative use of nursing time, etc.
Mapping Sheet Examples
Charge Reconciliation • Hospitals should implement a reconciliation process to ensure services provided per the “mapping sheet” match services billed. • “Mapping sheets” should be retained by the hospital and be readily accessible if requested by a Medicare auditor.
ER Level Distribution • Hospitals should monitor their ER level distributions on a quarterly basis. • This can be performed by graphically depicting the distribution of the ER facility codes as indicated on the following graph.
Summary • The amount a hospital charges ER patients should be based upon the hospital resources used in caring for that patient. • Resource utilization should be thoroughly documented and maintained as support for the level assignment. • ER medical records should be periodically compared to the detail bill and UB claim form to insure that all charges are appropriately charged and supported.
Strategies for Revenue Cycle Management Focusing on the Charge Description Master Module Three: Emergency Services If you have any questions or concerns regarding this course, please contact Mary Askew at firstname.lastname@example.org.