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
Tom Stec
Direct 913.322.9263
46
Save the Date
August 27-30, 2017
36th AHIA Annual Conference
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