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
How can you assure charge integrity
and proper reimbursement for your
facility?
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
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.
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
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…
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]
Revenue Management
& Reimbursement Department
Network Director
Observation and
Outpatients in Beds
Clinical Charge
Analyst
CHE
Clinical Charge
Analyst
CHN
Clinical Charge
Analyst
TIHH
Clinical Charge
Analyst
CHS
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
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
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
Revenue Management
& Reimbursement Department
Manager
Revenue Realization & Audit
Clinical Revenue
Analyst
Medical Imaging
Services
Clinical Revenue
Analyst
Emergency
Services
Clinical Revenue
Analyst
Surgical
Services
Clinical Revenue
Analyst
Women and
Children’s
Clinical Revenue
Analyst
Cardiovascular
Services
Clinical Revenue
Assistant
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
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]
APCs Weekly Monitor Subscriptionmonitoring 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.
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
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