*
Lisa Poworoznek
Director, Budget &
Reimbursement
Finger Lakes Health
May 22, 2014
Charge
Code
Description
Department
#
Facility assigned mnemonic, unique to one service
“Patient Friendly” description
General ledger department service performed within
Relative Value Unit
RVU
Revenue
Code
CPT/HCPCS
Multipliers
3 digit code categorizing the service: National Uniform
Billing Committee
Procedural Coding Systems: CPT – AMA
Pharmacy option – matches order to code
Adds additional procedure explanation
Modifiers
Charge
Amount
Exploding
Rules
HCPCS – CMS
CPT = Current Procedural Terminology HCPCS = Healthcare Common procedure Coding System
Financial fee assigned to line item
One charge code for two procedures always performed
together
*
* Exhibit 51 - ICR
PROVIDER NO. XX-XXXX NEW YORK STATE DEPARTMENT OF HEALTH VERSION: 2013.01
PERIOD FROM 01/01/2012 TO 12/31/2012 INSTITUTIONAL COST REPORT 05/31/2013 08:17:05
RATIO OF COST TO CHARGES - OUTPATIENT CHARGE MAPPING (REVENUE CODES) - PART III EXHIBIT 51
COST
CENTER
GROUP
45020
39
72
56
72
30
39
20
47
36
76
20
72
78
62
17
47
11
30
17
33
33
41
17
43
76
REVENUE
CODE
987
976
960
921
841
762
731
700
618
559
482
460
440
421
402
369
352
335
320
309
301
272
255
171
120
COST
CENTER
GROUP
45020
19
17
55
56
30
47
20
61
36
56
20
21
45
62
17
47
11
30
33
33
33
41
61
39
70
REVENUE
CODE
986
972
943
920
804
761
730
637
615
510
481
450
434
420
401
362
351
331
319
307
300
270
252
141
118
*
COST
CENTER
GROUP
45020
20
33
85
21
30
47
15
61
36
56
20
78
45
72
09
17
11
17
33
33
41
61
61
70
39
REVENUE
CODE
985
971
942
900
803
750
729
636
612
509
480
444
431
419
391
361
350
324
312
306
278
264
251
128
116
COST
CENTER
GROUP
45020
89
47
47
30
30
89
15
41
36
47
78
78
45
72
09
47
44
17
33
33
41
47
61
39
39
REVENUE
CODE
982
964
941
851
801
740
720
622
611
490
471
443
430
410
390
360
343
323
311
305
276
260
250
122
111
COST
CENTER
GROUP
45020
21
21
47
30
61
20
47
41
36
20
43
78
62
17
47
11
44
17
33
33
41
61
40
39
76
REVENUE
CODE
981
961
940
845
771
732
710
621
610
483
470
441
424
403
370
359
341
322
310
302
275
259
200
121
110
Department Ownership
Not Charged – Didn’t Happen
Percent of Charge
Payments
Reduces AR
Future
Rates
RCC
*
* MAC – Medicare Administrative Contractors
* CERT – Comprehensive Error Rate Testing Contractors
* ZPIC – Zone Program Integrity Contractors
* SMRC – Supplemental Medical Review Contractors
* Commercial Payors
* OIG – Office of Inspector General
* DOJ – Department of Justice
* OMIG – Office of Medicaid Inspector General
* MIP – Medicaid Integrity Plan
* Self Pay Patients
* Media
* Watch Groups
*
 “The second reason the compilation and release of this
data is a big deal is that it demonstrates the point I tried to
make in spotlighting the seven sample medical bills in
Time’s “Bitter Pill” report: most hospitals’ chargemaster
prices are wildly inconsistent and seem to have no
rationale. Thus the release of this fire hose of data—
which prints out at 17,511 pages—should become a tip
sheet for reporters in every American city and town, who
can now ask hospitals to explain their pricing.”
 The U.S. Department of Health and Human Services is releasing the
"chargemaster" price list of the 100 most common inpatient
procedures for all U.S. hospitals, inspired by Time's March 4 expose
on hidden medical billing.
*
May 1, 2014
Medicare IPPS Proposed Rule Includes Significant
Payment Changes for FFY 2015
* The Affordable Care Act (ACA) requires that hospitals "for each year establish
(and update) and make public (in accordance with guidelines developed by the
[Health and Human Services] Secretary) a list of the hospital's standard charges
for items and services provided by the hospital, including for diagnosis-related
groups established under Section 1886(d)(4) of the Social Security Act.“
* Until now, CMS has not issued the required guidelines. In the rule, CMS is
"reminding hospitals of their obligation to comply" with this requirement. CMS
states that its guidelines are "that hospitals either make public a list of their
standard charges (whether that be the chargemaster itself or in another form of
their choice), or their policies for allowing the public to view a list of those
charges in response to an inquiry." CMS does not provide a deadline for
compliance, but expects that hospitals will update the information at least
annually, or more often as appropriate, to reflect current charges.
*
HIM
Registration
Billing
Chargemaster
Department
Managers
Compliance
*
Clinical Order
Entry System
• Which is in tandem
with:
Medical
Record
HIM/Coding
*
• Which then ties to the:
Chargemaster
• Which maps with:
Billing
* Keeping Abreast of New Coding
Regulations
* Assess Contractual Issues for
Impacts
* Education Opportunities
* Evaluate Current Charge with
Active Listening
* Charge Forms/Tickets – Process
Review
* Partner with Billing to Assist and
Ensure “Clean Claims”
*
* Recommends Action to Avoid
Compliance Concerns
* Directs Chargemaster Review
Team in Ongoing Refinements
* Liaison between Finance and
Clinical
* Develop Policies and Procedures
* Maintance – Qtrly CMS, Monthly
Bulletins
* Evaluate Additional Charge
Capture Possibilities
Incorrect
Multipliers
Missing CCodes
Edits/Denials
Injectable
Drugs with
no
Injection
Charge
Setting
Implications
Revenue
Center
Mismatches
*
Outdated
Codes
*
*
*
*Medicare Guidelines state routine supply charges
will be bundled into the procedure, room rate or
leveling system.
- Routine Items: Gowns, Gloves masks, Blood Pressure
Cuffs, Ice Bags, IV Tubing, Pillows, Towels, Thermometers,
Wash Clothes, Soaps, Bed Linen, Diapers, Tourniquet,
Gauze, Band Aids, Oxygen Masks, Syringes, Wall Suction,
Drapes, Cotton Balls, Marking Pens, Pads, Urinals, Wipes,
Toothbrushes, Shaving Kits, Chucks, Shampoo, Etc……
*
Is this for a specific patient?
Non, Billable, Item is
Routine
No
Is the item reusable?
Yes
Is there a Physician order: Written, Verbal or
Implied?
No
Is medical necessity properly documented?
No
Non Billable, Bundled
into room/procedure
Non Billable, Personal
Non billable Without
What category does this fall into?
Take
Home
If needed to
facilitate
discharge
*
Implant
Low
Cost
Set Up
Tray/Kit
Procedure
Tray/Kit
Unique Item
or ordered
off shifts
Track
Independently
for ICR
Decide
threshold
– Bundle
Preparation
kits are not
chargeable
Review
each item
in kit: Ccodes
Communication
Emergency Department Charges
December 2013 YTD Stats
DEPT. MNEM.
PROCEDURE
**3001 30010014
CUTDOWN >1YR VENIPUNCT
**3001 30010015
ARTERIAL PUNCTURE
**3001 30010016
INTRAOSSEOUS NEEDLE IN
**3001 30010034
REMOVE FB EAR
**3001 30010035
REMOVE CERUMEN
**3001 30100001
SUTURE REMOVAL
**3001 30010001
ED VISIT LEVEL 1
**3001 30010094
HAND STRAPPING
**3001 30010091
APPLY FINGER SPLINT
**3001 30010085
EVAL SUBUNGAL
**3001 30010039
REMOVE CORNEAL FB W SL
**3001 30010036
REMOVE FB EYE-SUPERFIC
**3001 30010038
REMOVE CORNEAL FB
*
TECHNICAL CHARGES
2013 2013
2013
QTY CHARGE TTL CHRGS CPT REV SI
1
$40
$40 36425 450 X
6
$50
$300 36600 450 Q3
9
$450
$4,050 36680 450 X
5
$140
$700 69200 450 X
8
$14
$112 69210 450 X
89
$180
$16,020 99281 450 V
82
$180
$14,760 99281 450 V
1
$190
$190 29280 450 S
29
$169
$4,901 29130 450 S
1
$84
$84 11740 450 T
2
$271
$542 65222 450 S
2
$271
$542 65205 450 S
1
$271
$271 65220 450 S
RVU
0.3042
0.3042
0.7353
0.7353
0.7353
0.7658
0.7658
0.7685
0.7685
0.8370
1.0663
1.0663
1.0663
MU
1.00
1.22
1.00
1.00
1.04
1.00
1.00
1.00
1.09
1.27
1.00
1.00
UNIT EXTENDED MCR
BLUES Mark Up RECOMMEND
COST
COST
REIMB REIMB to MCR CHARGE
$14.00
$14 $20.47 $24.00 3.4
$70.00
$14.00
$84 $20.47 $30.00 3.4
$70.00
$33.84
$305 $49.48 $270.00 3.4
$169.20
$33.84
$169 $49.48 $84.00 3.4
$169.20
$33.84
$271 $49.48
$8.40 3.4
$169.20
$35.24
$3,137 $51.53 $108.00 3.4
$176.22
$35.24
$2,890 $51.53 $108.00 3.6
$183.00
$35.37
$35 $51.71 $114.00 3.4
$176.84
$35.37
$1,026 $51.71 $101.40 3.4
$176.84
$38.52
$39 $56.32 $50.40 3.4
$192.60
$49.07
$98 $71.75 $162.60 3.4
$245.37
$49.07
$98 $71.75 $162.60 3.4
$245.37
$49.07
$49 $71.75 $162.60 3.4
$245.37
* Hard Coding: For procedures performed the exact same way on
every patient. Applied by clinical personal performing the
procedure. 70,000 – 90,000 codes Assumes documentation is
present to support code
* Soft Coding: Medical record reviewed by coder and a procedure
code is applied from documentation – Mainly used with surgical
codes 10,000 – 60,000
* Collision Coding- Clinical applies hard code while HIM also soft
codes, results in duplicate charges. Watch for these situations.
*
*
- Encourages staff to perform and/or “check off”
services that are not required in order to
validate productivity
- Additional maintenance as line items grow
- Charge for services without medical necessity
- No substantiating documentation
- Stat definition varies from revenue definition
*
HIM
Registration
Billing
Chargemaster
Compliance
*
Department Managers
* Lisa Poworoznek
Director, Budget & Reimbursement
Finger Lakes Health
lisa.poworoznek@flhealth.org
*