1. Charge Description Master and Revenue Integrity: Putting the Pieces Together
Presented by:
Catherine (Kate) H. Clark, CPC, CRCE-I
Vice President
Maryland AAHAM, Past President

2. Objectives
This presentation will define and promote understanding of the following:
Charge Description Master (CDM) Defined
Revenue Integrity Defined
CDM Management Options
Revenue Integrity, CDM, and the Revenue Cycle – How can we do it better?

3. Polling Question #1
Respond to what role you play in relationship to the CDM/Revenue Integrity for your current position.
CDM Coordinator/Manager
CFO/CIO/COO/CEO
Revenue Cycle Staff
Finance/Reimbursement Staff
Contracting
Care/Case Management/CDI/Denials
Other

4. Why Now? Transition from Inpatient to Outpatient
Outpatient visits doubled from (50%)
Inpatient admissions grew by 13%
Outpatient charges impacted by charge capture (% of charges = Reimbursement)
Charge Capture Matters
Additional reimbursement
Accurate calculation of costs
Revenue Tracking by Department
Maryland – Global Budget through HSCRC
Non-Maryland – Ambulatory Payment Classifications (APCs)
Transition to Meaningful Use, Patient Experience, and Quality Measures -

5. Why Now? Electronic Medical Records (EMR) Timing and Resources
Cleaning Up before EMR is built
Preparation = Less Clean-up
Crosswalk of a “constant” current state to EMR build
Departments are responsible for Reconciliation (Revenue Integrity?)
Timing and Resources
January, October
Contracting updates for Non-Medicare payers
Updated Coding Guidelines
APC and HSCRC Updates

6. Polling Question #2
In your opinion, what is the most important function of the CDM?
Charge Capture
Compliance
Denials Management
Medical Necessity Verification
Point of Service Collections
Accurate Claim Submission
None of the Above
All of the Above

7. Source: http://en.wikipedia.org/wiki/Chargemaster
CDM Defined
Charge Description Master (CDM)
A comprehensive listing of items billable to a hospital patient or patient’s health insurance provider.
Master file built within the hospital information systems which is designed to interface with other software applications to support billing and reporting.
Fields include (but are not limited to):
Revenue codes
Current Procedural Terminology (CPT) or HealthCare Procedural Coding System (HCPCS)
Pricing
Service descriptions
Relative Value Units (RVUs) when applicable
Payer Specific Data Elements
Source:

8. CDM Defined CDM and the Claim Form
Has been described as “the central mechanism of the revenue cycle” of a hospital.
The CDM is closely linked to revenue generation. It is fundamental to the charge capture process.
Many CDMs are now being used as a component of revenue integrity validation.
CDM populates the claim form based on documented parameters, by payer, which decreases the number of “manual touches” by Patient Financial Services (PFS) staff.

9. Revenue Integrity Defined
Purpose: to prevent recurrence of issues that can cause revenue leakage and/or compliance risk.
• Revenue Integrity focuses on process improvements
• Revenue Integrity provides a check/balance system for the revenue cycle components, with support from leadership and technology.
Revenue Integrity
Stand-alone Department
Corporate Initiative
Organizational Structure

10. Components of CDM/Revenue Integrity
CPT/HCPCS
Units of Service
Rates/Pricing
Knowledge: Billing & Clinical
Charge Master
Reimbursement
PPS & Fee Schedules
Supply Chain & Pharmacy Mgmt
General Ledger
Complete & Correct Information = Paid Claims

11. CDM Management Options
Components to Consider
Risk
Relationships
Compliance
CDM Team
Meeting Attendance – enforced by leadership
Mandatory
Composition of the Team
Who participates
CDM Team Titles and Roles
CDM Staff
Translator-Explanation of Roles
Manager
Coordinator
Analyst
Finance Staff

12. CDM Management Options
Characteristics of effective CDM staff
Detail oriented
Inquisitive
Relentless
Highly organized
“Even” disposition
Good written and verbal communication skills
Quick

13. CDM Management Options – Set-Up
New Line Item Creation
Clinical
HIM
Rates and Reimbursement
Contracting
PFS
Financial Counseling/Patient Access
Sign-Off of New Line Item by Impacted Areas
Are services provided billable?
Do they translate to CDM line items?
Each Department to sign-off (see above) must contribute with their piece of the puzzle

14. CDM Management Options
Enterprise vs. Single-Entity CDM Management
Size of CDM
Order Entry mapping to correct CDM lines
Problematic for both entities, but moreso for Enterprise CDM
Fee Schedule Management within CDM
Updates
Multiple facility or enterprise builds with dedicated staff vs. single entity staff who are responsible for multiple roles.
Electronic Health Record – controlled by whom
Are providers Regulated and Non-Regulated

15. CDM Management Options
Internal vs. External CDM Management Options
Review goals of the CDM for organization
Cost of Vendor vs. Cost of Resources
Coordination of Information – NCD, LCD, Contracts
Implementation of changes
Communication with clinical staff
Information Technology interfaces
Data validation
Which option saves time or are more valuable?

16. Revenue Integrity and Revenue Cycle
CHARGE CAPTURE
MD ORDER ENTRY
SCHED & REG
ORDER ENTRY
BILLING
PAYER TABLE
CPT CODE
REV CODE
PRICING
RVU
HIM
CPT CODES
BILLING ============PAYMENT=============PFS

17. Revenue Integrity, CDM, & Revenue Cycle
CDM = Cash Flow
Updated CDM leads to faster cash
Scheduling
Clinical tests are scheduled based on CPT Codes
Patient balances calculated at time of scheduled procedure
Advanced Beneficiary Notice (ABN) Software
ABN executed based on CPT code assigned to test.
CPT is determined by CDM
Estimate patient balances if service is non-covered
(All non-covered services do not require an ABN)
Pre-Authorization
Services are pre-authorized with insurance companies based on the CPT code of the service.
Point of care collections – based on CDM pricing

18. Revenue Integrity, CDM, & Revenue Cycle
Charge Capture – Electronic or Manual
Electronic = Interface of charges through systems
Manual = Direct data entry into billing module
Both require accurate CDM set-up
Preference List (clinical charges) to CDM
Charge Entry from Clinical Staff or Charge Staff
Set-up must be determined before Preference list build
Order Entry Systems – Pyxis, Lab, Radiology, MUSE
Charge triggered based on parameters
Parameters defined by medical center, facility, or provider
Typically requires physician signature, physician order, or nursing entry

19. Revenue Integrity, CDM, & Revenue Cycle
Charge Capture – Electronic or Manual
Electronic Health Record (EHR) documentation
Automatic generation of charges through completed documentation
Encounter Forms
Completed by provider of care or designee
Manual entry into billing system
Typically direct data entry into billing system
Professional Fees
Triggered from Facility CDM
Professional Provider CDM

20. Revenue Integrity, CDM, & Revenue Cycle
UB-04 Claim Form
Billing of services performed to payers
Interface to billing systems or claim scrubber software
Bridge Routines – what is built behind the scenes for claim correction in order for them to be submitted to payers as “clean” claims.
Payer Tables
Compare patient insurance to payer information tables within the CDM to ensure accurate revenue and CPT/HCPCS information on the claim form.

21. Revenue Integrity, CDM, & Revenue Cycle
Health Services Cost Review Commission (HSCRC) (Maryland Hospitals Only)
HSCRC components are contained within the CDM as RVUs or prices for drugs and supplies
Rate compliance within each Department reported to the HSCRC
Outpatient Prospective Payment System (OPPS)
Pricing of services based on reimbursement
Bundled services – still built separately in the CDM as needed
Outlier Payments
Denials Management/Cash Posting
Communication of payer needs through denials and interface back to CDM
Denied services are communicated to the provider of care using specific HIPAA compliant denial codes.
Ongoing denial activity on specific line items must be communicated back to the CDM Team.
Correct Coding Initiative (CCI) Edits

22. Revenue Integrity, CDM, & Revenue Cycle
Health Information Management (HIM)
HIM coding of services within the hospital
No linkage to a specific CDM populated with CPT/HCPCS
HIM coded CPT/HCPCS codes must map to the appropriate revenue codes, which are identified in the CDM.
CDM mapping to specific revenue codes allows HIM coded services to cross to the claim form
Clinical Staff
Clinicians and Clinical Leadership must be involved with the set-up and maintenance of the CDM.
Denied services are communicated to the provider of care using specific HIPAA compliant denial codes.
Compliance
Each CDM that includes CPT/HCPCS, price, and quantity is subject to evaluation for compliance with billing and coding rules.
Correct Coding Initiative (CCI) Edits
Payer Edits

23. INSURANCE VERIFICATION PROGRAM ADMINISTRATION
CDM and Revenue Cycle
SCHEDULING
POST
PAYMENT REVIEW
REGISTRATION
EXPECTATIONS
CUSTOMER
REGULATIONS
INSURANCE VERIFICATION
CASH POSTING
PROGRAM ADMINISTRATION
POINT OF SERVICE
COLLECTIONS
SELF PAY COLLECTIONS
FINANCIAL CLEARANCE
CULTURE
PEOPLE
CUSTOMER
SERVICE
FINANCIAL COUNSELING
PROCESS
TOOLS
THIRD PARTY
FOLLOW- UP
DENIALS MANAGEMENT
CASE MGMT/QUR
BILLING
TECHNOLOGY
PAYORS
COMPLIANCE
CDM/CHARGE CAPTURE
MEDICAL RECORDS
Dependent
Related
Adapted from -Source:

24. Revenue Integrity within Revenue Cycle
What is it…
How is it different from Charge Capture (only)
How is it measured?
What tools are used?
How does current workflow or culture impact revenue integrity?
How do we know it is right?
Accountability
Oversight
Maintenance

25. CDM and Revenue Integrity
Key Strategies
• Create staff awareness
• Provide tools and/or guidance
• Design and implement a process for monitoring
• Development of tools
• Analysis of results to identify root causes
• Develop corrective action plans
• Track corrective action plan implementation
• Verify improvement
• Maintain oversight
• Reporting to leadership.

26. Polling Question #3
Has your facility performed a comprehensive CDM review within the past year?
Yes, completed using internal resources
Yes, using an outside firm
Yes, using both internal resources and outside firm
No, not within the past year
I Do Not Know

27. CDM and Revenue Integrity - Strategies
When are CPT Codes and CDMs Updated
Is there a schedule for general CDM Updates
Outreach to clinical areas
Outreach to PFS
Baseline validation of the CDM by external company
HSCRC review of RVUs for CDM validation
Review of each clinical area ensuring the CDM is accurate
Ensure Operational workflow is supported by accurate CDM set-up
Crosswalks between systems must be up-to-date and accurate (current file maintenance reduces interface errors and manual corrections)
EHR mapping of charges
Interface with HIM
Order Entry mapping to the CDM
Preference Lists mapping to CDM
Charge Documents – including professional fee (in hospital setting)

28. CDM and Revenue Integrity Strategies
Communication
Scheduling, Registration, Pre-authorization
Physicians, clinicians, or other providers
Patient Financial Services (PFS) – Facility and Professional
HIM, Denials, Nurse Auditors, CDI, Care/Case Management
Comprehensive CDM Review
Discussion
Education
Who teaches and relays the material
Who receives and is being trained on the material
What are the details of what is taught
How do you know the information is accurate

29. CDM, Revenue Integrity, and You
What can you do…
Understand the chain of command
Gather Facts – Reports, examples, data, results of queries
Communication – Not Personal, Direct, Focused
Ownership of Findings
Follow-Up
Follow- Up (x2) if Issue Not Closed
Doing the Work vs. Doing it Well

30. Final Comments Reimbursement Methodology
Does not change the need for a compliant and current CDM and Revenue Integrity Plan.
Updating the CDM
Policies and procedures
Code updates (at least 1x per year)
Inactivating or Added Services
Compliance Plan
Once a CDM policy and procedure is documented (frequency of review, how new line items are created, consolidating the CDM), it must be followed.
Revenue Integrity directly ties to compliance
Comment in Closing:
Stay current or you will never catch up

31. Questions Thank You! Catherine (Kate) Clark, CPC, CRCE-I
Vice President
Past President, Maryland AAHAM
(410)
Kohler HealthCare Consulting, Inc.
(410) – Office