Description
Insight Article
Top 10 Processes for a Compliant Chargemaster
By John Bartell, Health Care Consulting Partner
April 2016
The following list contains 10 important processes that are essential to
maintaining a compliant CDM. Studies have shown that many
hospitals, even those who routinely review their CDM, fail to
implement necessary changes to maintain a compliant CDM, which is
critical for payment accuracy. These 10 processes will help you be
proactive in reducing the potential for CDM errors.
1. Establish and maintain a Revenue Cycle Committee with one
person assigned to be the CDM Coordinator.
This position is responsible for making changes to the CDM, testing new or revised entries, and keeping abreast of coding, clinical service, and process changes that impact the CDM. For enhanced compliance and security, only the CDM Coordinator and a designated backup individual should have access to the CDM for additions, deletions, and revisions. 2. Research CMS and other payor updates.
The CDM Coordinator should monitor the Centers for Medicare & Medicaid Services (CMS) and other payor websites for updated coverage and coding and billing information that may impact the CDM. CMS updates its coding and billing instructions every quarter and annually. In addition, there are individual updates issued weekly—sometimes daily—so routine monitoring helps maintain accuracy with coverage, coding and billing. 3.
Conduct routine discussions with each department. All clinical departments should take responsibility for their respective portions of the CDM. Having a working knowledge of the CDM helps them to better understand the relationship between the CDM, patient care, and reimbursement.
The CDM Coordinator should conduct regular visits/meetings with each department lead, manager, and director for information exchange to keep abreast of departmental issues that may impact the CDM. 4. Review the entire CDM at least annually. An independent review of the CDM should be conducted by a third party at least biennially.
An independent assessment helps maintain objectivity while bringing the additional expertise that is often necessary with such a large and complex undertaking. 5. Conduct periodic chart-to-claim reviews. These reviews help ensure that key elements of the revenue cycle (e.g., CDM, charge capture, documentation, coding and billing) are functioning compliantly.
An arbitrary sample from each of the clinical areas provides a reliable “snapshot” of processes. Should an issue be identified, the CDM Coordinator or his/her designee should make sure it is resolved. A more extensive chart review should then be performed to ensure the problem has been fully addressed. 6.
Process additions, deletions, and revisions to the CDM only through the CDM Coordinator. Hospitals should have specific policies and procedures outlining the following information (at minimum) for requested changes such as date, requestor, item/service, requested charge, CPT/HCPCS code, and approve/deny authority. In addition, the CDM Coordinator should incorporate the input/approval of other key staff (e.g., HIM coders, finance, CFO). Their input is essential before any changes are made to the CDM. Finally, all changes to the CDM should be discussed at regular Revenue Cycle Committee meetings.
These processes help ensure the CDM remains compliant throughout the year. 7. Conduct regularly scheduled tests of CDM data. Routine testing of additions, deletions, and revisions to the CDM should be conducted to ensure the changes are working correctly in the billing system.
Creating “dummy” claims or test claims is one way to understand how CDM changes will impact claim production, accurate coding, and reimbursement. Accurate CDMs do not guarantee accurate claims. You need to ensure that the CDM data is not altered in the claim production process. 8.
Monitor and test claims on a regular schedule. Over time, billing systems are updated with newer versions, features, and “fixes” or to keep current with Medicare and commercial payor edits. When these updates occur, it is a good practice to monitor the CDM and resulting claims to ensure that the system updates did not cause negative changes to the CDM or claims production. 9.
Attend seminars and webinars. Clinical staff should attend CMS and commercial webinars on coverage, coding and billing Medicare items, and services. Listservs by CMS and their contractors provide valuable information as well.
Monitoring of MAC and RAC websites will provide insight into issues being investigated by Medicare. A variety of governmental and commercial publications are available to assist your staff in understanding the rules. These sources should be part of the Revenue Cycle Committee discussions because of the impact they may have on your facility’s CDM and corresponding reimbursement. 10.
Use caution when using commercial software to maintain the CDM. These maintenance programs are available commercially and offer providers a means to keep their CDMs current and compliant. However, caution should be exercised in using these programs because they may leave an impression that the CDM is “taking care of itself.” This “hands off” approach may lead to compliance risks.
Similar to #5 and #7 above, routine testing should be conducted to ensure compliant reporting. . Insight Article About the Author About Wipfli’s Health Care Industry Practice John Bartell, RN, BSN, Partner Wipfli’s national health care practice has nearly 100 associates dedicated to serving more than 1,800 clients in 45 states, including integrated delivery systems, large community hospitals, critical access and rural hospitals, physician practices, and senior living organizations. Wipfli can advise in all areas of business, from finance and operations to human resources, information technology, and reimbursement. For more information, visit www.wipfli.com/healthcare. John is a partner and co-leader of Wipfli LLP’s (“Wipfli’s”) revenue cycle consulting practice with 34 years of clinical, audit, and assurance experience. This experience includes more than 14 years of expertise with Medicare requirements on clinical, financial, and compliance criteria for billing. He is proficient in the identification of hospital revenue cycle financial and compliance risk factors that impact operations.
In addition, John has developed charge capture audit processes and unique chargemaster compliance review programs that are highly effective tools to assist providers in maintaining compliance while optimizing reimbursement. Should you have any questions concerning these issues, or would like more information on how to make your chargemaster more compliant, please call John at 414.431.9349 or email him at jbartell@wipfli.com. About Wipfli LLP With more than 1,500 associates, 32 offices in the United States, and 2 offices in India, Wipfli ranks among the top 20 accounting and business consulting firms in the nation. For over 85 years, Wipfli has provided private and publicly held companies with industry-focused assurance, accounting, tax, and consulting services to help clients overcome their business challenges today and plan for tomorrow.
For more information, visit www.wipfli.com. .
This position is responsible for making changes to the CDM, testing new or revised entries, and keeping abreast of coding, clinical service, and process changes that impact the CDM. For enhanced compliance and security, only the CDM Coordinator and a designated backup individual should have access to the CDM for additions, deletions, and revisions. 2. Research CMS and other payor updates.
The CDM Coordinator should monitor the Centers for Medicare & Medicaid Services (CMS) and other payor websites for updated coverage and coding and billing information that may impact the CDM. CMS updates its coding and billing instructions every quarter and annually. In addition, there are individual updates issued weekly—sometimes daily—so routine monitoring helps maintain accuracy with coverage, coding and billing. 3.
Conduct routine discussions with each department. All clinical departments should take responsibility for their respective portions of the CDM. Having a working knowledge of the CDM helps them to better understand the relationship between the CDM, patient care, and reimbursement.
The CDM Coordinator should conduct regular visits/meetings with each department lead, manager, and director for information exchange to keep abreast of departmental issues that may impact the CDM. 4. Review the entire CDM at least annually. An independent review of the CDM should be conducted by a third party at least biennially.
An independent assessment helps maintain objectivity while bringing the additional expertise that is often necessary with such a large and complex undertaking. 5. Conduct periodic chart-to-claim reviews. These reviews help ensure that key elements of the revenue cycle (e.g., CDM, charge capture, documentation, coding and billing) are functioning compliantly.
An arbitrary sample from each of the clinical areas provides a reliable “snapshot” of processes. Should an issue be identified, the CDM Coordinator or his/her designee should make sure it is resolved. A more extensive chart review should then be performed to ensure the problem has been fully addressed. 6.
Process additions, deletions, and revisions to the CDM only through the CDM Coordinator. Hospitals should have specific policies and procedures outlining the following information (at minimum) for requested changes such as date, requestor, item/service, requested charge, CPT/HCPCS code, and approve/deny authority. In addition, the CDM Coordinator should incorporate the input/approval of other key staff (e.g., HIM coders, finance, CFO). Their input is essential before any changes are made to the CDM. Finally, all changes to the CDM should be discussed at regular Revenue Cycle Committee meetings.
These processes help ensure the CDM remains compliant throughout the year. 7. Conduct regularly scheduled tests of CDM data. Routine testing of additions, deletions, and revisions to the CDM should be conducted to ensure the changes are working correctly in the billing system.
Creating “dummy” claims or test claims is one way to understand how CDM changes will impact claim production, accurate coding, and reimbursement. Accurate CDMs do not guarantee accurate claims. You need to ensure that the CDM data is not altered in the claim production process. 8.
Monitor and test claims on a regular schedule. Over time, billing systems are updated with newer versions, features, and “fixes” or to keep current with Medicare and commercial payor edits. When these updates occur, it is a good practice to monitor the CDM and resulting claims to ensure that the system updates did not cause negative changes to the CDM or claims production. 9.
Attend seminars and webinars. Clinical staff should attend CMS and commercial webinars on coverage, coding and billing Medicare items, and services. Listservs by CMS and their contractors provide valuable information as well.
Monitoring of MAC and RAC websites will provide insight into issues being investigated by Medicare. A variety of governmental and commercial publications are available to assist your staff in understanding the rules. These sources should be part of the Revenue Cycle Committee discussions because of the impact they may have on your facility’s CDM and corresponding reimbursement. 10.
Use caution when using commercial software to maintain the CDM. These maintenance programs are available commercially and offer providers a means to keep their CDMs current and compliant. However, caution should be exercised in using these programs because they may leave an impression that the CDM is “taking care of itself.” This “hands off” approach may lead to compliance risks.
Similar to #5 and #7 above, routine testing should be conducted to ensure compliant reporting. . Insight Article About the Author About Wipfli’s Health Care Industry Practice John Bartell, RN, BSN, Partner Wipfli’s national health care practice has nearly 100 associates dedicated to serving more than 1,800 clients in 45 states, including integrated delivery systems, large community hospitals, critical access and rural hospitals, physician practices, and senior living organizations. Wipfli can advise in all areas of business, from finance and operations to human resources, information technology, and reimbursement. For more information, visit www.wipfli.com/healthcare. John is a partner and co-leader of Wipfli LLP’s (“Wipfli’s”) revenue cycle consulting practice with 34 years of clinical, audit, and assurance experience. This experience includes more than 14 years of expertise with Medicare requirements on clinical, financial, and compliance criteria for billing. He is proficient in the identification of hospital revenue cycle financial and compliance risk factors that impact operations.
In addition, John has developed charge capture audit processes and unique chargemaster compliance review programs that are highly effective tools to assist providers in maintaining compliance while optimizing reimbursement. Should you have any questions concerning these issues, or would like more information on how to make your chargemaster more compliant, please call John at 414.431.9349 or email him at jbartell@wipfli.com. About Wipfli LLP With more than 1,500 associates, 32 offices in the United States, and 2 offices in India, Wipfli ranks among the top 20 accounting and business consulting firms in the nation. For over 85 years, Wipfli has provided private and publicly held companies with industry-focused assurance, accounting, tax, and consulting services to help clients overcome their business challenges today and plan for tomorrow.
For more information, visit www.wipfli.com. .
