Chargemaster (CDM) and Fee Schedule Reviews

Many Medicaid programs, Medicare, managed care companies, and other payers reimburse hospitals using the Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) coding system. Because of the dramatic shift from inpatient to outpatient care, hospitals must carefully monitor their outpatient revenues to remain financially viable and competitive in today’s market.

AMS Consulting Services comprehensive Charge Description Master (CDM) review process evaluates the hospital’s Medicare billing practices in these critical areas:

Review of the CDM

To improve accuracy and timeliness of claims processing, many HCPCS/CPT codes are listed in the CDM. AMS consultants will help the hospital ensure that all necessary codes are in the CDM, that they are properly linked to the correct universal billing form UB-04 revenue code, and that the codes accurately describe the procedures performed.

Department Manager Interviews

The AMS consultant meets with each ancillary department to clarify the procedures/services performed by the hospital and to familiarize hospital staff with coding requirements and interpretations. During the interview we also review the department’s charge sheets and documents to ensure that the codes and descriptions used by the department match those listed in the CDM. In some cases, accurate billing and coding may necessitate revisions to charge documents and billing procedures.

Review of Outpatient Medical Records

The most effective process for validating the accuracy of HCPCS/CPT codes is to review the medical record. With the cooperation of the Health Information Management (HIM) Department, we review a cross-section of Medicare outpatient records to assess the accuracy of coding. Our sample covers outpatient surgery, gastroenterology (GI) lab procedures, emergency room, cardiac catheterizations, chemotherapy, and other diagnostic services. We also include some cases in the record review which have been denied payment by the Fiscal Intermediary. Through this process, we are able to identify the causes of most outpatient billing problems.

Review of Billing Documents

For each of the medical records reviewed, we also compare clinical documentation to the actual billing document. It is common to find problems in the interfaces among the various clinical and financial information systems. The only way to verify that the process results in accurate billing is to compare the final bill to the services documented in the medical record. Our final report identifies problems found in the translation of codes to the patient accounting system and other billing errors, such as incorrect bill types, or incomplete UB-04 forms.

Implementation Assistance

Our report is delivered and reviewed on-site with the hospital staff. We assist you in assigning priorities for implementation of the report recommendations. Our report is organized so that each department manager can review and implement changes for his or her department. Because our focus and strength is in working with hospitals, we ensure that all recommendations conform to regulations for the hospital setting.

Finally, AMS Consulting Services will provide on-going support service for a ninety (90) day period from completion of the CDM project.

For further information regarding the CDM Review, please Contact Us