DeMystifying the Chargemaster for CAHs prepared for FLEX - Florida CAH Financial Improvement Collaborative Copyright 2015 ChargemasterCare™

Facilitators Sarah L. Goodman, MBA, CHCAF, COC (CPC-H), CCP, FCS Kenneth Wolfgang, FCS, PCS, CPC, COC (CPC-H) Copyright 2015 ChargemasterCare™

Disclaimer Every reasonable effort has been taken to ensure that the educational information provided in today’s presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation.

Course Objectives On completion of this session, attendees will be able to: Describe the function, organization and pricing of the CDM in a CAH Identify issues impacting a typical CAH CDM Relate to the CDM maintenance and reimbursement process of a CAH Copyright 2015 ChargemasterCare™

What is the Chargemaster? A Chargemaster is a file containing all of the procedures, services, pharmaceuticals, supplies, and professional fees provided by a hospital or under hospital contract and billed on a UB-04 and/or CMS-1500. Sometimes referred to as a CDM or Charge Description Master, it may contain several thousand lines and is system- driven. Copyright 2015 ChargemasterCare™

CDM Structure All hospitals whether PPS, a CAH or a specialty facility such as a cancer or children’s hospital have a CDM of some sort. Key elements of the CDM include: Charge Code Description HCPCS/CPT Revenue Code Patient Charge Copyright 2015 ChargemasterCare™

CDM Pricing Although CAHs are cost-based reimbursed under Medicare, like many PPS hospitals, they price services based upon a markup—typically 2 to 3 times—the published OPPS Ambulatory Payment Classification (APC) rate for the procedure. Supplies and pharmaceuticals are generally priced based on a factor of cost or ASP. Copyright 2015 ChargemasterCare™

CAH CDM Issues In a CAH, incorrect revenue codes can impact current payments since reimbursement is cost-based under Medicare. Thus, the major Medicare concern in the CAH CDM is revenue coding. Revenue codes tell a payer where or in what department a service was provided to a patient. Copyright 2015 ChargemasterCare™

CAH CDM Issues Revenue codes are required for Medicare billing in both CAH and PPS hospitals, and are uniformly used by all payers. However, there may be some variation in what certain payers want to see on the claim, e.g., 0761 vs. 0510. Revenue codes are “hard-coded” in the hospital charge master and are automatically assigned when a charge is entered. Copyright 2015 ChargemasterCare™

CAH CDM Issues CMS uses a revenue code to cost center crosswalk to estimate the cost of services. This data is then used to set future hospital outpatient APC payment rates. In a CAH, incorrect revenue codes can impact current payments. Copyright 2015 ChargemasterCare™

CAH CDM Maintenance PPS and CAH CDMs are very similar, but reviewing and maintaining them varies slightly. In some cases, certain codes applicable to OPPS hospitals do not apply in the CAH setting, e.g., G0463 vs. 99201-99215. While the PPS CDM review would focus on areas unique to DRG and APC payments, the CAH CDM focus is primarily on areas related to cost-based reimbursement. Copyright 2015 ChargemasterCare™

Contact Information Course facilitators will receive and respond to questions addressed to: Sarah Goodman at Sarah@chargemastercare.com Ken Wolfgang at Ken@chargemastercare.com Or by telephone 800-244-8284