Term
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Definition
| From registration to payment |
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Term
| The reimbursement process begins |
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Definition
| when the patient presents for services |
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Term
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Definition
| is a master inventory list of all procedures, services, pharmaceuticals, devices, and supplies that can be reported or performed in the hospital. Approximately 75 percent of outpatient services are driven by the CDM. |
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Term
| A chargemaster may also be called |
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Definition
| charge description master (CDM) or a service master. |
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Term
| Specifically what is on the CDM |
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Definition
| list of CPT and HCPCS codes used by the hospital and its specific departments to identify procedures, drugs, and supplies applicable to their specialty. Also are Uniform Billing (UB) revenue codes, charge descriptions, and other services. These services are identified by the department performing the service. |
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Term
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Definition
| When you select codes using the CDM. Charges are automatically posted on the UB-04 form through the billing system, without hospital coder involvement. Ie. the code is already built into the system not entered manually. |
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Term
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Definition
| Codes entered in the system by the coder are said to be directly coded or soft coded. Not all services can be coded using the CDM; more complex cases, such as surgeries and ED encounters, must be coded by HIM Staff. |
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Term
| common problem with a chargemaster |
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Definition
| is obsolete or outdated codes. |
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Term
| Each department should review its CDM |
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Definition
| at least annually. Also when coding or payment policy changes. |
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Term
| Comprehensive overview of the CDM is recommended |
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Definition
| at least every three years. Many hospitals enlist an outside firm. |
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Term
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Definition
| are returned from payers to indicate paid, denied, and suspended claims. |
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Term
| CDM is usually maintained by |
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Definition
| CDM coordinator or the Revenue Integrity Department. Critical to APC reimbursement because claim items without a code will not be reimbursed. |
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Term
| Updates to the chargemaster are typically performed by |
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Definition
| The Revenue Integrity Department, and the CDM coordinator, with the assistance of the clinical department manager, the patient financial services office(billing), and the HIM department. Also maybe the information management service, the compliance department. |
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Term
| When changes to the chargemaster increase or decrease revenue what department should review the impact |
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Definition
| The Finance/Accounting Department |
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Term
| If changes in chargemaster changes revenue so drastic that it creates cost outliers, and a dramatic increase in reimbursement who should be notified |
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Definition
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Term
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Definition
| supplies paid outside of the APC package |
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Term
| The minimal data a hospital may include in CDM |
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Definition
| Department number, Unique Billing Code (UBC)/inventory number, Description of services, Revenue center (UB revenue code), Procedures codes, charge for service |
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Term
| In addition to the minimum data in the CDM many facilities also include |
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Definition
| modifiers, cost information, number of times the service is billed, and alternate codes required by payers. |
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Term
| Medicare reimburse outpatient clinic visits with what code |
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Definition
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Term
| A significant amount of billing information for a patient encounter is derived from |
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Definition
| Chargemaster. Although individual department will generate charges. |
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Term
| Diagnosis and procedure codes may be assigned by |
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Definition
| registration personnel, medical coders, other members of the HIM or Health Information Services (HIS) department, or the billing staff in the patien financial services office. |
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Term
| The symbol *** on chargemaster means |
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Definition
| indicates those services do not have a code built into the CDM |
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Term
| Im most hospitals, coding is performed in several areas, including |
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Definition
| Provider-based clinics, Health Information Management Department, Ancillary Clinical Departments |
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Term
| CDM task force also called |
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Definition
| Revenue Integrity Department |
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Term
| The CDM task force is responsible for |
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Definition
Reviewing the CDM, at least anually
Maintaining updates throughout the year as new procedures or supplies are incorporated into the hospital's service line.
Reviewing payer information and making CDM adjustments based on that information. |
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Term
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Definition
| general billing questions for a facility, general code assignment for all areas of CPTand HCPCS with emphasis on outpatient surgery coding and ICD 10 diagnosis coding, understanding of the purpose of revenue codes and chargemasters (dont memorize) |
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Term
| If there is not a line item describing a service the department provides |
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Definition
| The department will request additions to the CDM. |
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Term
| Code updates for CPT go into effect |
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Definition
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Term
| HCPCS code updates are done |
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Definition
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Term
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Definition
Ensuring all codes are valid.
Deactivate outdated or unused codes
Add new codes.
Evaluate all unlisted CPT codes.
Verify that the code description is accurate and corresponds to the CPT/HCPCS level II descriptor.
When review is complete, compare to Medicare's Outpatient Code Editor (OCE) to determine if any services should not be billed.
Review CPT/HCPCS for correct UB revenue code assignment.
Evaluate 4 digit of revenue code to ensure accuracy.
Review for more appropriate revenue code assignment.
Ensure all outpatient services have a corresponding code and monitor for duplication of services.
Review departmental charge tickets to ensure codes correlate to CDM.
Review sample UB-04 form prospectively, and remittance advice notices retrospectively, to verify information. |
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Term
| Deactivated codes are a result of |
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Definition
| obsolete procedures no longer performed at the facility or deleted codes |
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Term
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Definition
| used when there is not a CPT code to accurately describe the procedure performed. Watch for when new codes are released as there may be a code for previously unlisted procedure. |
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Term
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Definition
| Outpatient Code Editor edits the claim and assigns information needed for payment. ie. APC status indicators, payment indicators, etc. |
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Term
| UB Revenue codes or revenue code are |
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Definition
| four digit codes used to identify teh departments where services were provided or the type of service. |
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Term
| The fourth digit in the revenue code |
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Definition
| describes a more specific service. |
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Term
| Each department will have a unique billing code which links to |
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Definition
| the UB revenue code and CPT or HCPCS. Helps track resources used in each department. |
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Term
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Definition
| a review of the documentation and the claim form before the claim is sent to the payer. |
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Term
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Definition
| is a review of the documentation, the claim, and the payment information after the claim is paid. |
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Term
| Ten steps to a successful Chargemaster Review |
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Definition
Determine type of review to be conducted.
Assemble a cross-functional review team.
Establish project leader or liaison.
Allocate resources to the process.(done internal or external, # employees/ hours needed to complete review.
Establish the communication mechanism for the team. (department notified when services in CDM are updated).
Download complete CDM and distribute to team.
Schedule and prepare for departmental reviews.
Conduct interviews and review line item, per department.
Research CDM related issues.
Finalize changes to the CDM and report to the appropriate department. |
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Term
| Cross-functional review team should include |
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Definition
| employees from coding, billing, denials management, clinical staff, and members of the Revenue Integrity Department. |
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Term
| The project leader of chargemaster review is usually |
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Definition
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Term
| In the cases where the services are not in the CDM and being entered manually by the coder there will be |
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Definition
| a time-based charge or flat fee for the surgery to capture the charges. CPT code will attach to that charge and will be matched with the revenue code for that service on the UB-04. |
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Term
| Where does registration occur |
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Definition
| It can occur in one of several outpatient hospital departments. ie. dialysis services, ed, outpatient clinic etc. |
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Term
| The registration process depends on whether the patient is |
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Definition
| is scheduled or not scheduled for services |
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Term
| For all encounters the staff registering the patient will obtain |
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Definition
| demographics, insurance information, and an account is created for the date of service and all charges will be posted to the account. |
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Term
| Insurance verification is done |
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Definition
| prior to patients visit if scheduled, and during registration if unscheduled. |
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Term
| What information is collected during insurance verification |
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Definition
| patients responsibility and if authorization is required, if the facility participates with the patients insurance. |
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Term
| Failing to obtain patients insurance information or pre-authorization can result in |
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Definition
| the claim not being able to be processed/claim being denied and loss of revenue |
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Term
| preauthorization for scheduled surgical services is done |
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Definition
| prior to date of surgery and usually clinical information is needed from surgeon before payer will authorize. |
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Term
| preauthorization in emergency situations is done |
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Definition
| when its determined the patient requires surgery. priority is patient care can be obtained prior to patients release. |
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Term
| do all payers require authorization |
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Definition
| no. facilities need to understand requirements for each payer. |
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Term
| Collecting patients copayments |
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Definition
| should be collected prior to patient leaving, prior to scheduled service, or prior to discharge if in the ed. |
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Term
| During the patient encounter the |
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Definition
| clinicians document services rendered. Important for medical services to support medical services billed. |
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Term
| During an audit the medical documentation |
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Definition
| is reviewed to make sure all services billed were performed and documented. |
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Term
| Without adequate documentation can you bill the services |
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Definition
| the services should not be billed |
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Term
| What if you receive payment and documentation doesn't support the services |
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Definition
| The facility must refund the payer. |
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Term
| During patients care charges are entered by |
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Definition
| various departments involved in their care. Each department will post charges to the patient's account. |
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Term
| When the charge is entered into the system the revenue codes are assigned via |
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Definition
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Term
| The HCPCS and CPT codes are assigned |
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Definition
| by either using the CDM for non surgical and supplies or manually by the coding staff. |
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Term
| Who typically assigns the ICD 10 codes |
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Definition
| coding staff or outpatient staff department |
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Term
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Definition
| compiling charges, revenue codes, all codes for services, in the billing software. |
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Term
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Definition
| claims are run through this to make sure they are clean. If has errors they are corrected by the billing department prior to submission to payer. |
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Term
| examples of errors on claim |
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Definition
| invalid codes, missing digits in the insurance policy, or medical necessity edits when dx doesn't support the procedure performed. |
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Term
| Current electronic format required by HIPAA |
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Definition
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Term
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Definition
staff registers patient -getting demographics, insurance and creating account.
services are documented by clinicians involved in patient care.
Charges entered into system by the departments involved.
revenue codes assigned via chargemaster when the charge is entered.
Codes entered for the services rendered either by CDM or coders.
coding staff (or outpatient dept) assigns dx codes.
Information transferred to billing dept.
claims created and run through claim editing system(scrubber).
claims with errors reviewed and corrected.
Claims now sent to payer.
Payer adjudicated the claim (paid or denied or suspended).
Billing dept receives eob or ra.
Payments, adjustments, denials are posted.
Denials researched. corrected and resubmitted or an appeal may be done.
statement mailed to patient for their responsibility. |
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Term
| common reasons for denial |
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Definition
| incorrect coding, terminated insurance coverage, incorrect insurance information, lack of prior authorization |
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Term
| The information on an eob or ra includes |
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Definition
| payment amount (if any), adjusted amount, and patient responsibility, and if denied reason for denial. |
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Term
| denied claims originally correct and the payer made the mistake you can |
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Definition
| file an appeal for the claim to be reconsidered. |
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Term
| Typical Ambulatory Surgical Center Flow |
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Definition
| Its really the same as outpatient except that the scheduling staff needs to review the list by Medicare of surgeries that are not approved for ASCs. If not approved the provider needs to be informed. |
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Term
| Medicare has a list of surgeries that are not approved for ASCs called |
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Definition
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Term
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Definition
| yearly on CMS website with the OPPS final Rule. |
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Term
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Definition
| four digit codes representing departments where services were provided. |
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Term
| if an audit determines that a particular procedure performed has inadequate documentation in the medical chart the services should |
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Definition
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Term
| In a typical hospital's CDM layout what does *** indicate about the services |
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Definition
| does not have a CPT/HCPCS code built into the CDM |
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Term
which is true about the chargemaster:
a services can't be coded using the chargemaster
b it must be updated when coding changes occur.
c A comprehensice review is recommended every year.
d A department review should be performed monthly. |
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Definition
| b it must be updated when coding changes occur. |
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Term
| Statement is sent to the patient as soon as |
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Definition
| payments are posted and denials are resolved. |
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Term
| Which digit in a revenue code assignment describes a more specific service? |
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Definition
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Term
| When changes to the DM results in a dramatic increase in revenue, which group should review the impact of these changes to revenue? |
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Definition
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Term
| Which group is responsible for CDM review, at least annually, maintaining updates throughout the year, and reviewing and maintaining payer information? |
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Definition
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Term
| Appropriateness of care refers to |
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Definition
| The proper setting of medical care to best treat the patient's diagnosis. |
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Term
| One thing the COC exam will not cover is |
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Definition
| The assignment of PCS codes |
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Term
| What are two ways codes are reported for outpatient services |
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Definition
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Term
| How are claims sent to most payers |
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Definition
| electronically in format required by HIPAA |
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Term
| Who is responsible for creating medical documentation? |
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Definition
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Term
| When do new CPT and HCPCS codes go into effect? |
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Definition
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Term
| When a UB_04 claim is reviewed retrospectively, this means |
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Definition
| The claim is audited for correctness after being sent to the payer. |
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Term
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Definition
| Medicare Administrative Contractor |
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Term
| The reimbursement process begins when |
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Definition
| The patient present for services |
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Term
| If a claim that is not clean or complete is submitted to a payer, it will be returned to the billing department with a denial explanation. Reasons for denial include: |
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Definition
| Incorrect insurance information, incorrect coding, lack of prior authorization |
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Term
| Services included in the CDM are identified by |
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Definition
| The department performing the service |
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Term
| In outpatient surgery facilities, patient copayments, when required, are collected: |
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Definition
| Prior to the patient leaving the facility. |
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Term
| When a hospital outpatient arrives for a scheduled appointment, insurance verification |
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Definition
| is verified prior to the patients scheduled appointment |
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Term
The chargemaster may include:
a modifiers
b alternate codes required by payers
c number of times the service is billed
d all of the above |
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Definition
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Term
| If a code change in the CDM increases or decreases revenue, the person responsible for the chargemaster should |
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Definition
| refer the issue to the Finance/Accounting Department |
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