ENHANCING REVENUE

CYCLE AUDITING WITH

DATA ANALYTICS

KATHY LANGLEY &

TOM STEC

DATA ANALYTICS AUDIT

MANAGERS

CHAN HEALTHCARE

AHIA 35th Annual Conference – September 11-14, 2016

www.ahia.org

1

Learning Objectives

1. Identify data sets and essential elements for

analytics

2. Discuss revenue cycle background basics and

predictive indicators

3. Explain why charges matter

4. Describe how to research, validate and report

potential exceptions

2

Revenue Cycle 3

Patient Access

HIM

Charging

Billing and Collecting

• Registration

• CDM

• Charge Capture

• Managed Care

Contracts

• Late Charges

• Inherently

tested in

Charge

Capture and

Managed Care

contract

modeling

Patient Access 4

The Hospital’s Front Door

Patient Access – Key Data 5

Demographic HIM Coding (Diagnosis

Codes)

Insurance and Financial Class Tables

Patient Access – Specific Testing

Registration Data Integrity

Duplicate/Multiple Medical Record Numbers

Insurance Data Collection

Admitting Diagnosis Documentation

6

Charge Description Master (CDM)

A comprehensive, hospital specific listing of each item that

could be billed to a patient, payor, or health care provider

7

CDM #

Description

CPT/HCPCS

Code

Revenue

Code

Charge

Amount

3603550 Surg Initial 30 360 4,616.00

3603551 Surg Addl 15 360 2,308.00

1450523 ER Visit Lvl III 99283 450 1,112.00

2965288 Therp Infsn Init Up to 1 Hr 96365 450 375.00

7612011 Therp Infsn Init Up to 1 Hr 96365 761 434.00

6360659 Bortezomib 3.5 mg Inj J9041 636 8,650.00

2508698 Lidocaine 10 mg/ml Inj 250 19.55

4901010 Chest Single Vw 71010 320 246.00

4120069 Renal Funct Pnl 80069 300 281.00

CMS Addendum B 8

HCPCS

Code

Short Descriptor

SI

APC

Payment

Rate

99283 Emergency dept visit J2 5023 195.98

96365 Ther/proph/diag iv inf init S 5694 173.18

J9041 Bortezomib injection K 9207 46.82

71010 Chest x-ray 1 view frontal Q3 5521 60.80

80069 Renal function panel Q4

CDM - Compliance

Invalid or Terminated CPT/HCPCS Codes

Revenue Code Assignment

Drug Dosages

NOS Codes

Hard Coded Modifiers

9

Invalid/Terminated CPT/HCPCS Codes 10

CDM CPT/HCPCS SERVICE REVENUE CHARGE

# CODE DESCRIPTION CODE AMOUNT

426010080 73500 CR HIP 1 VW 320 189 .00$

464016050 C1720 SEEDSRADIOACTIVEPD- 103 278 80 .00$

416500152 J0151 ADENOSINE PER 30 MG 636 115 .76$

Revenue Code Assignment 11

RECOMMENDED

CPT/HCPCS SERVICE SERVICE CHARGE REVENUE REVENUE

CODE CODE DESCRIPTION AMOUNT CODE CODE

3 6 4 15 5 5 7 0 0 0 0 0 1 VENIPUNCTURE - ER 15 .7 5$ 3 0 0 REVCDS: 0 3 3 0 ;

0 3 6 0 ; 0 3 6 1; 0 4 5 0 ;

0 4 9 0 ; 0 5 10 ; 0 5 14 ;

0 5 15 ; 0 5 16 ; 0 5 17 ;

0 5 19 ; 0 7 6 1

7 6 7 0 0 5 7 0 2 8 0 0 6 0 US ABDOMEN COMPLETE 9 7 3 .3 5$ 3 2 0 REVCDS: 4 0 2

C17 7 8 5 5 0 0 18 7 8 9 LEAD KT SPN P ISCES QUAD 2 8 2 5 8 7 7 8 13 ,7 9 7 .0 0$ 2 7 8 REVCDS: 2 7 5

J3 4 2 0 5 3 8 0 13 15 7 VITAMIN B- 12 INJ 2 2 .18$ 4 8 0 REVCDS: 0 2 5 0 ;

0 6 3 6

Q9 9 6 7 5 7 0 0 2 0 9 0 0 L CT ISOVUE 3 0 0 /ML 1.2 9$ 6 3 6 REVCDS: 0 2 5 4 ;

0 2 5 5

C18 8 5 5 5 0 0 113 15 CATH TURBO ELITE 2 .0 2 3 2 6 2 2 7 ,4 4 1.8 8$ 2 7 2 REVCDS: 2 7 8

Drug Dosages 12

CPT/HCPCS

Code

Status

Indicator

Long Description

J9263 K INJECTION, OXALIPLATIN, 0.5 MG

J9320 K STREPTOZOCIN, 1 GM

J9033 K INJECTION, BENDAMUSTINE HCL, 1 MG

J2860 G INJECTION, SILTUXIMAB, 10 MG

CDM – Pricing and Reimbursement

CDM Pricing vs APC Payment Rates

Lab Pricing vs Medicare Lab Fee Schedules

Implants with Supply or Drug Revenue Code

Duplicate CPT/HCPCS with Disparate Pricing

Zero Priced Items

Completeness

Addendum B not on CDM

Managed Care Fee Schedules not on CDM

Managed Care Pricing – more to come

Comparison to Competitor Pricing

13

CDM Pricing vs. APC Reimb Rates 14

LABOR

CDM REV SERVICE CPT/HCPCS CHARGE ADJ

# CODE DESCRIPTION CODE AMOUNT APC RATE DIFFERENCE

404027818 450 TREATMENT OF ANKLE FRACTURE 27818 655 .20$ 983 .68$ 328 .48$

426074379 360 L XA CAR COM + BIF +ARCH 36223 3 ,354 .91$ 3 ,406 .09$ 51.18$

432009001 412 METERED DOSE INHALER TX 94640 98 .70$ 134 .09$ 35 .39$

Implants with Supply or Drug Revenue

Code 15

SERVICE SERVICE CPT/HCPCS REVENUE CHARGE

CODE DESCRIPTION CODE CODE AMOUNT

5 5 4 0 8 8 8 0 8 MESH HERN 3 D MAX XL 5 X7 IN R 2 7 2 1,12 3 .2 0$

5 5 4 0 8 8 3 3 8 2 4 1.3 6 1 TUBULAR PLATE 6 HOLE 1/3 2 7 2 5 3 9 .2 7$

5 5 4 0 0 10 4 0 FRACTURE SPINE ADD FX 18 3 3 4 1 2 7 2 7 ,6 4 0 .18$

4 0 0 8 12 4 8 8 ROD FIX 11X3 0 0 MM C FBR 12 3 9 4 8 2 7 2 4 0 8 .8 4$

4 2 6 0 7 9 5 2 3 ZS G V IABAHN RP STNT 7 X10 5 0 6 2 12 C18 7 6 2 7 2 13 ,2 5 9 .4 0$

Disparate Pricing 16

CPT/HCPCS CDM CHARGE REV SERVICE

CODE DEPT # AMOUNT CODE DESCRIPTION

11401 ERM 404011401 985 .3 9$ 4 5 0 EXC BNIGN LESN TRK EXT 0 .6 - 1.0CM

11401 HBO 954011401 1,175 .5 5$ 3 6 0 EXC LSN TRK ARM LEG 0 .6 TO 1.0 CM

6 2 2 7 2 ERM 4 0 4 0 6 2 2 7 2 928 .6 5$ 4 5 0 SPINAL PUNCTURE TX DRAINAGE CSF

6 2 2 7 2 RAD 426011545 1,0 5 8 .81$ 3 2 0 CR FLUORO GD LUMBAR PUNCT TX

6 2 2 7 2 RAD 426074165 957 .6 0$ 3 6 0 XA SPINAL DRAIN PLACEMENT

Charge Capture

Emergency Department

Surgery

Other Departments

Cath Lab

Interventional Radiology

Oncology

Lab

Maternity

17

Why Do Charges Matter? 18

Reimbursement

CPT/HCPCS codes and revenue codes % of

charge payors

Carve-out payments

Outlier payments

Failed Edits

Cost Report

Future Rate Setting

Managed care

contract negotiations

• Compliance issues

• Internal staffing

needs

Charge Capture – What and How

Predictive indicators/pairings

If you find X on a patient account, then you should find

Y charge(s) on that patient account

X defined using various indicators: Patient log files,

CPT/HCPCS codes, ICD10 diagnosis or procedure codes,

DRGs, etc.

Y defined using various indicators: CPT/HCPCS codes, UB04

revenue codes, hospital specific CDM charge codes, etc.

Partner with clinical experts

19

Charge Capture – Key Data 20

Demographic Detail

Charge Transactions

HIM

CDM Other

(Scheduling Logs)

Emergency Department

What happens in the ED?

What charges can/should we test for?

Evaluation and Management (E&M) levels

Surgical procedures and CPT codes

Drug administration

Initial

Initial/Add-on Hierarchy

Radiology/Imaging

Others

21

ED – Identify Population 22

Admission

Source Patient

Type

Hospital Service

or Location

ED – E/M Level Charges

Total ED population

Levels 1-5 and critical care

CPT/HCPCS codes 99281-99285, G0380-G0384,

99291

“Dummy” level charges

Facility/Technical vs Physician/Professional

Duplicate level charges

23

Critical Care

Level 5 Level 4 Level 3 Level 2 Level 1

ED – Surgical Charges & CPT Codes 24

SERVICE SERVICE CPT/HCPCS REVENUE

CODE DESCRIPTION CODE CODE

4 5 0 0 0 0 13 7 5 LAC RPR S IM FACE 2 .6 - 5 CM 12 0 13 4 5 0

4 5 0 0 0 0 13 9 0 LAC RPR INT BODY/SCLP/EXTM2 .5 CM 12 0 3 1 4 5 0

4 5 0 0 0 0 0 0 6 0 APPLY SHORT LEG SPLINT 2 9 5 15 4 5 0

4 5 0 0 0 0 0 6 6 5 NASAL HEMORRHAGE, ANT S IMPLE 3 0 9 0 1 4 5 0

4 5 0 0 0 0 0 4 3 0 FB CORNEAL W/O SLIT LAMP 6 5 2 2 0 4 5 0

4 5 0 0 0 0 0 4 3 5 FB EAR 6 9 2 0 0 4 5 0

SERVICE SERVICE CPT/HCPCS REVENUE

CODE DESCRIPTION CODE CODE

3 7 8 0 10 9 1 PROCEDURE LEVEL I 4 5 0

3 7 8 0 10 9 1 PROCEDURE LEVEL II 4 5 0

3 7 8 0 10 9 1 PROCEDURE LEVEL III 4 5 0

ED – Drug Administration

Injection or Infusion

Administration is not part of procedure

Anesthesia drug – surgical procedure

Contrast medium – radiology procedure

Not vaccines

Not chemotherapy drugs

Not fluids/hydration

Initial vs. Add-on

25

ED – Drug Administration 26

CMS

SERVICE SERVICE REVENUE CPT/HCPCS CPT/HCPCS

CODE DESCRIPTION CODE CODE SHORT DESC

2821517 INSULIN REGULAR HUMAN PER 5 UNITS 636 J1815 Insulin injection

338004904 SODIUM CHLORIDE 0.9% 0.9 % SOLP 1,000 ML BAG 636 J7030 Normal saline solution infus

409379501 KETOROLAC 30 MG/ML (1 ML) SOLN 1 ML VIAL 636 J1885 Ketorolac tromethamine inj

409427902 LIDOCAINE (PF) 10 MG/ML (1 %) SOLN 30 ML VIAL 636 J2001 Lidocaine injection

904198280 ACETAMINOPHEN 325 MG TAB 250

150012502 ONDANSETRON 4 MG/2 ML SOLN 2 ML VIAL 636 J2405 Ondansetron hcl injection

Which drug charges should typically have an accompanying

administration charge?

ED – Drug Administration 27

CMS

SERVICE SERVICE REVENUE CPT/HCPCS CPT/HCPCS

CODE DESCRIPTION CODE CODE SHORT DESC

2821517 INSULIN REGULAR HUMAN PER 5 UNITS 636 J1815 Insulin injection

338004904 SODIUM CHLORIDE 0.9% 0.9 % SOLP 1,000 ML BAG 636 J7030 Normal saline solution infus

409379501 KETOROLAC 30 MG/ML (1 ML) SOLN 1 ML VIAL 636 J1885 Ketorolac tromethamine inj

409427902 LIDOCAINE (PF) 10 MG/ML (1 %) SOLN 30 ML VIAL 636 J2001 Lidocaine injection

904198280 ACETAMINOPHEN 325 MG TAB 250

150012502 ONDANSETRON 4 MG/2 ML SOLN 2 ML VIAL 636 J2405 Ondansetron hcl injection

ED – Drug Administration 28

CMS

CPT/HCPCS CPT/HCPCS

CODE SHORT DESC

96360 Hydration iv infusion init

96361 Hydrate iv infusion add-on

96365 Ther/proph/diag iv inf init

96366 Ther/proph/diag iv inf addon

96367 Tx/proph/dg addl seq iv inf

96368 Ther/diag concurrent inf

96369 Sc ther infusion up to 1 hr

96370 Sc ther infusion addl hr

96371 Sc ther infusion reset pump

96372 Ther/proph/diag inj sc/im

96373 Ther/proph/diag inj ia

96374 Ther/proph/diag inj iv push

96375 Tx/pro/dx inj new drug addon

96376 Tx/pro/dx inj same drug adon

96379 Ther/prop/diag inj/inf proc

C8957 Prolonged iv inf, req pump

ED – Drug Administration Hierarchy 29

Order of Hierarchy Substance Administered

Chemotherapy

Therapeutic, Prophylactic, Diagnostic

Hydration

Order of Hierarchy Method of Administration

IV Infusion

Pushes

Injections

AND

ED – Radiology Imaging

Subset of the ED population

Fractures, Head Injury, Spinal Injury

30

Population Identifiers

• ICD10 Diagnosis Codes

Charge Identifiers

• CPT Codes

• UB04 Revenue Codes

ED – Other Charge Test Examples

Hospital’s protocols

Chest pain - EKG, Chest xray, Cardiac enzymes

Trauma activation

Inhalation treatment and drugs

Vaccines and vaccine administration

31

Surgery Department

What happens in the surgery department?

What charges can/should we test for?

Time/procedure

Anesthesia services

Recovery services

Implants

Thresholds

Vs. supplies

32

Surgery – Identify Population 33

Surgery

Log Data Elements

• Patient Account #

• Service Date

• Anesthesia Type

• Location (OR

Name/Number)

Main OR

Labor & Delivery Cath Lab

GI Lab OP Surgery Center ? ?

OR Time and/or Surgical Procedure

Initial time charges

Surgical procedure charges

Charge identifiers: revenue codes, CDM charge

codes, CPT codes

34

Anesthesia and Recovery Services

Anesthesia

Initial time

When is it not charged?

Charge identifiers: revenue codes, CDM charge codes

Recovery

Initial time

When is it not charged?

Charge identifiers: revenue codes, CDM charge codes

35

Implants/Devices

Subset population

Charge identifiers: revenue codes, CDM charge

codes, HCPCS codes

Dollar thresholds

Implants as supplies

36

Other Department Charges

Cath Lab

Procedures – cardiac cath, stent

Implants/devices – stents, pacemakers, leads

Interventional Radiology

Paired codes/charges

Radiology/imaging

Surgical procedure

Nuc med procedures

Radiopharmaceuticals

37

Other Department Charges

Oncology

Drugs and administration

Brachytherapy

Lab

Procedures requiring blood draw

Maternity

Delivery

Newborn protocols

38

Charge Capture – Addressing Exceptions

Judgmentally sampling on population identifier

Judgmentally sampling by service/department

Reviewing records with department staff

Update assumptions and re-perform analysis

as appropriate

39

Late Charges

Charges posted subsequent to the bill hold period

Easily performed with other revenue cycle audits

Late charges always result in some loss for the entity

40

Managed Care

Perform contract modeling to determine payor

compliance

Analyze pricing to identify lost opportunities

41

Managed Care – Key Data 42

Demographic Detail Charge,

Payment, Adjustment Transactions

HIM

CDM

(including payment/adjustment

transactions)

Other (Payor Code Tables)

Contract and Related Tables /

Schedules

Managed Care – Contract Modeling 43

Expected Reimbursement

• DRG Rates

• Case Rates

• Fee Schedules

• % of Charges

• Carve Outs

• Stop Loss

VS Actual Reimbursement

Managed Care - Pricing

Lower of charge or contracted rate scenarios

Fee schedule CPT/HCPCS not on CDM

Excessive charges

Zero balance, no payments

One contractual adj = charges

Multiple contractual adjs = charges

Multiple contractual adjs

Total payments = total charges

44

Key Takeaways 45

1. Opportunities for improvement can be found

throughout the revenue cycle

2. Partner with operational and clinical staff to identify

predictive indicators and potential tests

3. Charges matter!

For more information contact:

Kathy Langley

Direct 850.994.6262

klangley@chanllc.com

Tom Stec

Direct 913.322.9263

tstec@chanllc.com

46

Save the Date

August 27-30, 2017

36th AHIA Annual Conference