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CRCR Recertification

Study notes

Importance of Gap Analysis: Helps identify where the largest opportunities to improve revenue quickly. Also demonstrates the amount of opportunity which may be realize for a successful RIP. Becomes work plan for the program.
Revenue Integrity Area of Work: In Clinical In Clinical Space - Charge Capture, charge capture algorithms, ED level charges and CDI (clinical document improvement).
CDM (Charge Description Manager): In order to correctly report all aspects of the services provided, capture and format information required for billing. Providers must develop, maintain & optimize the CDM.
CDM Optimization: It is not enough to simply build the chargemaster & review on a regular basis. Audit processes must be developed & implemented to compare the medical records with the final bill generation for those services.
Late Charges: Another Revenue Integrity issue involving the use of the CDM is the posting of late charges. Late charges are defined by each provider organization, most commonly as charges posted to in account more than 3 days from date of service.
Charge Reconcilation: An often overlooked activity involving the CDM is the system integration from clinical systems to billing systems. Robust reconciliation procedures are essential to ensuring that all daily chgs. are passed from 1 system to the other.
Coding CPT-4 & ICD-10: Are the 2 coding systems in use for hospital claims. All coding must be validated by the clinical records. Falsification of coding is a serious compliance violation punishable under the False Claims Act.
Accurate Claims: Clean claim edits are an important measurement tool to id failure rates before claims are submitted to payers. Rate total # of 837 claims released from the claims processing tool w/ manual intervention / by total # accepted by claims processing tool
Timely Billing: Payers have enacted specific require for the timely filing of clms. Accting system s/have timely filing rules for 3rd party payers to ID & create warnings if a claim is approaching deadline.
Other Revenue Integrity Opportunities: Part I HIM components, cooperation between HIM staff, clinical staff & revenue cycle staff is essential to maximize coding activities & ensure clean clms. are produced on a daily basis.
Strategic Pricing: Pricing is the process of estab. a defensible price for svcs. Considerations incl. costs assoc. w/ the product, test or svc., the competitive landscape w/in the providers's svc. area, & markup that can be explained based on cost & margin.
Claim Denials: Represent a major focus in revenue integrity work. Failure to recognize the importance of denial prevention as well as resolution of denials results in significant revenue losses.
Measurement of Denials: Map Keys used to track denial activity at the strategic level. Remittance denial rate is the vol. indicator; the net denial dollars written off indicator reflects the final loss of revenue & cash to the organizations.
Regulatory Issues Included in Revenue Integrity Programs: Focus is on providers compliance w/ payer rules, espec. those rules est. by MC & Medicaid regulation. Addtl. State regulations may deal w clean claims pymt requirements, timely filing rules & other payer requiremts. MC Compliance rules s/b incl. in RIP.
Inpatient vs Obs Admit Status 1: Physician decision based on pt's medical hx, current med. needs & medical predictability of something adverse happening to the pt.
Inpatient vs Obs Admit Status 2: Med. Doc. must support the level of care provided. Pt. admitted to inpt. status if further tx can only be provided in a hosp. setting & condition cannot be tx in 24hrs.
Inpatient Part B Only Billing 1: When MC pymt cannot be made because an inpt. admissions is found to be not reasonable & necessary & the pt. should have been tx as a hospital outpt. rather than hosp. inpt.
Inpatient Part B Only Billing 2: It will not pay for those svcs that specifically require an outpt status, such as outpt. visits, ER visit, & OBS svcs, that are by definition, provided to hosp. outpt. & not inpts.
Part B Payments: May only be made if the patient is enrolled in Part B, the allowed timeframe for submitting claims is not expired, and waiver of liability pymts is not made.
Two Midnight Rule: CMS created the 2 midnight rule to more clearly define what should be considered inpt. admission. *If admitting practitioner expected the pt. to require a hospital stay that crosses 2 midnight's & med. rec. supports that reasonable expectation.
MC DRG 3-Day Pymt Window Outpt Window-Outpt Svcs Pre-admission dx svcs provided to a MC pt by hosp on date of pt's inpt admit or during the 3 cal days / IPPS hosp 1 cal day are required to be included on the bill for inpt. stay unless there is not Part A coverage.
IPPS Inpatient prospective payment system
Outpatient Non-Diagnostic Svcs (other than Ambulance & Maint. Renal Dialysis Svcs.) Hospitals must attest when specific non-diagnostic svcs. are unrelated to hosp claim by adding condition code 51 to the separately billed outpt non-diagnostic svcs claim.
Code 51 Attest of unrelated outpatient non-diagnostic services
Violation of the DRG Window1: Prov who repeatedly violate the DRG window rules may receive addtl sanctions, inclu monetary fines, revocation of MC status & criminal sanctions under the FCA.
Violation of the DRG Window2: Most hospitals are subject to these billing rules & the rules apply to hospitals operation under Medicare's IPPS
FCA False Claims Act
Medicare 2nd Payer Rules - Medicare is never liable when it involes: *Work Comp *Veterans Affairs *Black Lung *Federal Grants or Public Health Svcs *MC Advantage Plans
Medicare maybe secondary *Working aged *ESRD *Liability *Disability Issues involving MSP rules will often identified through the review of MC denials.
ESRD End Stage Renal Disease
MSP Medicare Second Payer
Fee for Service (FFS) Part A Hospital Insurance Program - Automatically enrolls persons 65 & older. Understating the various Medicare options is critical to determining if MC claims are correctly processed and paid.
Fee for Service (FFS) Part B Voluntary Portion of Medicare
Fee for Service (FFS) Part C Medicare Advantage
Fee for Service (FFS) Part D Prescription Drug Plan for Medicare Beneficiaries
Fee for Service (FFS) Medicare As part of the Revenue Integrity Program, MC and managed care plan denials are reviewed to ensure that the correct payer has been identified and billed.
Staffing the Revenue Integrity Team1: The team is multidisciplinary team operating typically under charter from the CFO, CMO, CNO & COO
Staffing the Revenue Integrity Team2: Team staffing involves recruiting team members w/ clinical & financial backgrounds & skills.
Staffing the Revenue Integrity Team3: Examples Clinical skills of Nursing & Ancillary Managers, but also Analytical & Financial skills of the data analysts & payer specialists. Finance & Marketing, Health & Human Physiology, Acturial Science, Acct., Economics, Economics & HIM
HIM Health Information Management
Other Revenue Integrity Projects: Examples A/R workflows; work from home productivity, outbound scheduling call unit, pricing strategy, dashboards, MC Bad Debt, charge capture algorithms. Physician co-pay collections,
Other Revenue Integrity Projects: Examples2 Revenue Analysis based on orders, Vendor management-specific programs such as TPL (third-party liability) Auto Liability, Etc.
A successful Revenue Integrity Program Includes 1: A team of Clinical & Financial Personnel aligned around a specific product line.
A successful Revenue Integrity Program Includes 2: Process & Procedures designed to monitor, identify & mitigate charge & coding discrepancies
A successful Revenue Integrity Program Includes 3: A focus on regulatory issues & Internal monitoring of compliance
A successful Revenue Integrity Program Includes 4: Monitoring of reimbursement & identification of variance
Result of a focused, well-designed Revenue Integrity Program & Work Plan: Will identify opportunities to reduce or eliminate revenue leakage, claim management rework & regulatory application discrepancies for the organization.
DRG Diagnosis Related Group
KPI Key Performance Indicators
The first step in any revenue integrity program work? Is to identify the gaps where the hospital or health system is losing revenue.
Gap Analysis Work Plan By updating on a regular basis, management can demonstrate successes & identify additional opportunities to reduce or eliminate revenue leakage.
Major Area of Revenue Integrity - Charge Capture 1) Room & Bed Charges 2) Ancillary Charges
Room & Bed Charges 1) Are typically posted from the midnight census 2) Based on the room & accommodation or level of care associated w? the room that the patient occupies as of midnight.
Ancillary Charges Part I 1) Can be posted either when the svc or supply is ordered or when a result is reported. 2) Frequently included an interfaced transfer of data from the clinical system, such as a laboratory system, to the patient accounting system.
Ancillary Charges Part II 3) Are generated by scanning barcoded items or other forms of documentation as items are used. Ex. Surgery or materials management enter charges unrelated to testing or items that are not barcoded.
Ancillary Charges Part II 4) Are frequently charged based on length of time (surgery) or acuity (nursing).
What is an Audit Trail? The typical audit trail is a charge audit report that is verified against logs, schedules, and the medical records to ensure that all resources consumed during patient care are charged to the appropriate patient account.
How are charges grouped? Charges are typically grouped by revenue codes for billing, logging, & case mix reporting. Because charge descriptions can vary greatly between providers, many items now have CPT-4 or HCPCS supply codes attached making it easier to compare & track.
What is the impact of missing charges captured by an audit trail? 1) Revenue is understated 2) Coding may be impacted & incorrectly described the service which may cause a false claim for svcs. 3) Svc. department's productivity data will be understated
Revenue Integrity Area of Work: In Reimbursement Area CDM optimization, strategic pricing & contract modeling are part of the revenue integrity program.
Revenue Integrity Area of Work: In Patient Financial Svcs. Routine monitoring of transfer DRGs, contract adjudication, availability of alternative payers, review of all 3rd party liability claims, denials, early out program design & identification of physician underpymts are essential components of program.
Timely & accurate capture of charges for services provides The most appropriate measurement of utilization of resources.
Resource Management 1) Allows more timely & accurate billing & collecting which improves net collections & cash flow. 2) Ensures bills do not have to be held for late charges. 3) Decreases research efforts questions related to duplicate charges, charge codes, are reduced
CDM consists of: List of services/procedures, room accommodations, supplies, drugs/biologics, & or radiopharmaceuticals that may be billed to a hospital inpt or outpt. It also includes the charge-specific data needed for claim submission.
A typical CDM line item includes: 1) a # assigned to a dept. 2) a description 3) a dollar amt. 4) CPT or HCPCS codes 5) any applicable modifiers 6) applicable revenue code NUBS 7) General ledger code which directs the revenue to the appropriate department.
CDM challenges include: 1) Omission of charges 2) Obsolete or invalid codes 3) Omission of required modifiers
Maintenance of CDM should include: 1) Billling 2) compliance 3) Managed Care 4) Info Systems 5) HIM 6) Svc Are Depts (charge generation dept) 7) Physicians responsible for creating & review medical protocals
What factors can have an adverse effect on reimbursement 1) Incomplete or vague documentation 2) coding from face sheet or incomplete records. Coders making mistakes in identifying, coding, & sequencing diagnoses & procedures. 3) Physicians using symptoms instead of specific diseases in their dictation.
CDM It is critical that the CDM be updated regularly & ongoing education s/b provided to staff to ensure code & description changes are communicated to the appropriate svc area depts.
A robust Revenue Integrity Program will identify Late charge issues thru a chart to charge audit of random sample accts. Late charges discovered after the claim is submitted may be denied or submitted beyond timely filing deadline.
Charge Reconciliation Validation Activities 1) Patient lists 2) Services 3) No Shows 4) Error messages
CDI (Clinical Documentation Improvement) programs Uncovers lapses in clinical documentation. A common CDI program finding is failure of clinicians to document all the HCC's applicable to a pt service.
HCC Hierarchical Condition Codes
Best Practice for Timely Filing Denials Should be a zero-tolerance policy. With appropriate procedures and controls in place, these denials are avoidable.
Other Revenue Integrity Opportunities: Part II Scrubber edits s/b included such as CCI edits, modifiers requirements, bundling requirements.
CCI Correct Coding Initiative
Clean Claim Production Rate Should approach 95%. Clean claims are important because they should be paid promptly by the payer reducing denials and other payment delays.
Data needed to validate the accuracy of payer claim processing includes: 1) Original claim as billed to the payer 2) Contract terms applicable to the claim 3) Amounts identified on the remittance advice from the payer as total charges, contractual allowance, patient's responsibility and payer's payment.
Revenue Integrity Team Shares payment issues with Contract Management team for resolution with the payer.
Hospital Observation Is an outpatient bedded patient status that is used to elevate patient from possible inpatient admission or to resolve problems where the tx is expected to last less than 24 hours.
Inpatient vs Obs Admit Status 3: Hosp. can convert an inpt. to obs. if the hosp. utilization review committee determines before d/c and billing. Phy. must be notified, agree to, & document this change.
QIO Quality Improvement Organizations Rather than MAC Medicare Admin Contractors or RACs perform all compliance review for ex. 2 Midnight Rule.
Revenue Integrity Projects examples Pricing strategy, dashboards, Medicare bad debt, charge capture algorithms.
Other Revenue Integrity Projects Scorecards with drill down capability are important to allow discussion of issues at the account level, while providing the accumulated, comprehensive viewpoint. Also create accountability at the operational level.
Created by: annabelle.wurtz
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