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  1. Charge Integrity- Protecting the Bottom Line for your Facility Tina Rosier, M.S., P.T., CPC Community Health Network Revenue Realization and Audit, Manager March 3, 2011

  2. How can you assure charge integrity and proper reimbursement for your facility?

  3. Objectives • Determine ways to help protect your facility’s bottom line • Review why it is important to charge for all services provided • Share • Ideas for how to ensure the integrity of your charge description master [CDM] file • Processes for how to assure department accountability for charge capture • Ways to audit and improve charge capture and compliance before the claim leaves your facility

  4. Importance of Charge Capture and supporting Documentation • Documentation:If we do not accurately and completely document the services then we cannot charge, cannot bill, and will not receive payment. • Money: Some payers pay by CPT/case rate, but some pay by percentage of charge. Charge for all you do! • Future Money: Medicare reviews claim data for the services we provide today… and uses this data to determine future reimbursement rates. • Lost Money: If we are audited by a payer after they have paid us and cannot show them supportive documentation for the service, the payer will take their money back.

  5. Chargemaster Integrity • Software/tools [Craneware, Code Correct, Medi-Regs] • Reviews [annual at a minimum is recommended] • Internal vs. consultant/company • Monthly check based on input given by our software • Valid/Invalid CPT/HCPCS coding • Revenue code to CPT code mismatches • Deleted/replaced CPT/HCPCS coding • Drugs and J-code validation • Annual review starting in July that analyzes coding and pricing for an annual rate adjustment

  6. Chargemaster Integrity [cont’d] • Check step to approve every new charge added to charge master file • Charge Integrity Committee review, if indicated • Network Charge Integrity Committee • Purpose: To continuously monitor, assess, and define the hospital charging practices of the Community Health Network to ensure compliance and uniform application of charge practices across all entities. • Objective: To interpret and define the payer guidelines and regulations governing appropriate charging practices and processes as it relates to the rendering of hospital services, and to act as the formal decision making body as it relates to the development of charging policy for the Community Health Network. • HIM, Legal, Managed Care, Internal Compliance, Billing, Revenue and Reimbursement, Audit, etc…

  7. Clinical Department Accountability: Documentation and charge entry • Documentation to support charges • Valid physician orders, supporting diagnosis/medical necessity • Clinical notes • Reports/Results • Policy for charge entry timeliness • Assigned staff for charge entry • ED, CCL, Surgery, Radiology • Clinical Charge Analysts, nursing units [next slide]

  8. Revenue Management & Reimbursement Department Network Director Observation and Outpatients in Beds Clinical Charge Analyst CHE Clinical Charge Analyst CHN Clinical Charge Analyst CHS Clinical Charge Analyst TIHH

  9. Clinical Charge Analyst • One FTE assigned at each hospital • Responsible for chart review following discharge to complete charge capture/entry for all nursing units where Observation and outpatients in a bed receive care/services. • Provide feedback to clinical staff and management on documentation improvements needed to assure maximum charge capture • Start/stop times for drug admin • Start/stop times for blood administration • Need for valid physician order on chart

  10. Clinical Department Accountability [cont’d] • Reconciliation tools • Radiology/Imaging system [IDX] daily log report • ED/Daily ED patient log out of HBOC/STAR system • Surgery/Horizon Surgical Manager [HSM] reports • Auditing and/or Peer review

  11. Pre-billing Accountability:Revenue Realization and Audit Team • Goals: • Help the Network to maximize revenue and ensure charge compliance through the Quality Improvement Process (QIP) • Representation for high volume and high dollar service lines • Assure that claims are accurate and clean prior to billing the payer • Decentralized audit team with both decentralized and centralized functions

  12. Revenue Management & Reimbursement Department Manager Revenue Realization & Audit Clinical Revenue Analyst Medical Imaging Services Clinical Revenue Analyst Women and Children’s Clinical Revenue Analyst Emergency Services Clinical Revenue Analyst Surgical Services Clinical Revenue Analyst Cardiovascular Services Clinical Revenue Assistant

  13. Clinical Revenue Analyst • Experts in clinical/financial systems and processes • RNs, LPNs, Certified coders • Patient flow observation from admit to discharge • QIP mapping of current and future state charge capture processes [on-site visits] followed by QIP team meetings to manage a plan to improve all charge capture related processes for the service line • HPM/HBI System “alerts” for problem accounts [70+] • Blood products w/o blood admin charges • Duplicate Drug admin initial service • Pacemaker procedure w/o a device code • CT with contrast w/o contrast charges

  14. Clinical Revenue Analyst [cont’d] • Assist with identification of new chargeable services and set up in charge description master • Maintenance of departmental charge sheets and charge definition documents • Assist with failed claims from billing department [biller questionnaire process] • CCI edits, modifier appropriateness? • Rev code and CPT/HCPCS mismatches • Missing device code • DOS issues • Monitor web sites for changes • APCs weekly, Medicare/NGS.gov [see next slide]

  15. APCs Weekly Monitor Subscription- monitoring websites APCs Weekly Monitor, January 7, 2011 Q: Did CMS provide any new updates for hyperbaric oxygen (HBO) therapy services for 2011? A: Based on the 2011 OPPS final rule, HCPCS code C1300 (hyperbaric oxygen under pressure, full body chamber, per 30 minute interval), which falls within APC 0659 (hyperbaric oxygen therapy) with a national unadjusted payment rate of $104.99, did not change. However, CMS told providers that claims reporting only a single occurrence of the code were anomalies. CMS noted that this was either because the claim reflected a terminated session or because the service was incorrectly coded with a single unit. Therefore, we urge providers to audit their claims to ensure that: • Documentation of the service reflects the time of the service• The units reported reflect the documentation• The units are reported and submitted correctly based on the actual service time and not defaulted to one because no time increment was documented Review CMS’ National Coverage Determination for Hyperbaric Oxygen (HBO) Therapy 20.29 for more information.

  16. Clinical Revenue Analyst [cont’d] • Manage day to day “how to charge” questions • Work with systems team on charge exception reports [charges that fail to interface from clinical system to accounting system] • DOS issues • Invalid charge number used • Invalid account used • Communication of all audit data, charge capture errors, and trends to department leadership • Team completes ~750 audits per month

  17. Other Network Initiatives • PCON/Contract management team to assure appropriate payment • Internal Compliance team • Network RAC committee [Medicare recovery audit contractors] • Post-payment commercial claim audits