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CRIP, Section 1
Certified Revenue Integrity Professional - overall review of charge capture
| Question | Answer |
|---|---|
| Common UB-04 codes - Condition Codes | Identify conditions relating to the bill that may affect payer processing. ex 17, pt is homeless / 21, billing for denial / 44, IP admission changed to OP |
| Common UB-04 codes - Occurrence Codes | Identify the specific date defining a significant event relating to the bill that may affect payment processing. ex: 04, Accident; employment related / 11, date of onset of symptoms or illness / 33, First day of ESRD coordination period |
| Common UB-04 codes - Value Codes | Identify values of monetary nature ex: 02, Hospital has no Semi-Private Rooms / 41, Black Lung / 48, Hemoglobin Reading |
| Common UB-04 codes - Revenue Codes | Identify a specific accommodation, ancillary service or bill calculation. ex: 260 - IV Therapy / 320, Radiology / 480 - Cardiology |
| Explain and describe the UB-04 | Uniform Bill - required when billing hosp IP & OP, SNF's, Home Health Practitioners, OP Rehab facilities, community mental health centers, etc. Contains 81 data elements with field locators with information re: treatment and condition of the patient. |
| List negative impact of not properly maintaining CDM | - Claim rejections - Under/Over Payments - Under/Over Charges -Potential fines/penalties -RAC take-backs (Recovery Audit Contractor) |
| List benefits of properly maintaining CDM | - minimize billing errors - Foster pricing transparency - helps maintain compliance - Improve operating margin of the co. - Support consistent process to establish charges - Supports consistent order entry - drives > 70% of rev cycle $ |
| RAC | Recovery Audit Contractor |
| When would on initiate a charge request form? | - Initiating a charge - Updating a charge - Inactivating a charge |
| What is CDM and describe | Charge Description Master: Master pricing list of supplies, meds, devices, svcs, procedures and other items for which a distinct charge to the patient exists. CDM contains all info needed for facility billing. |
| What information is stored in the CDM? | - Charge Descriptions - Costs - Rev codes - Current Procedural Terminology (CPT) Codes - Healthcare Common Procedure Coding System (HCPCS) Codes - Modifiers (on rare occasions) |
| What does RBRVS and what is it? | Resource Based Relative Value Scale: - pmt reform provision, part of Omnibus Budget Reconciliation Act (OBRA) of 1989. |
| What are the 3 major elements of RBRVS? | - Fee schedule for pmt of physician svcs based on relative value units. - MC volume performance standards (MVPS) for rates of increase in MC expenditures for phys svcs. - Limits on amts non-participating physicians can charge beneficiaries |
| What are limiting charges | Part of RBRVS, limts the amount a non participating physician can charge a beneficiary. (This is 115% of the fee schedule amount) |
| Name the alpha prefixes found in Level 2 HCPCS codes and describe | C = Temporary hospital OPPS codes G = Temporary procedures and professional services J = Drugs administered other than oral method or chemo P = Pathology and Laboratory V = Vision and hearing svcs |
| Describe Level 1 HCPCS Codes | CPT Codes, 5 digit numeric 6 Sections: - E/M - Anesthesia - Surgery - Radiology - Pathology & Labs - Medicine *Level 1 codes don't include items or svcs that are regularly billed by suppliers other than physicians |
| Describe Level 2 HCPCS Codes | 5 digit codes w/ alpha prefixes A-V - Products, supplies and services not included in Level 1 codes. ex: Ambulance svcs / DMEPOS |
| LCD - what does it mean and explain | Local Coverage Determination: - Policies developed by MC Area Contractors, specify criteria for svcs and show under what clinical circumstances an item/svc is considered reasonable, necessary and appropriate. LCD can't conflict with an NCD. |
| NCD - What does it mean and explain | National Coverage Determination: Medical review policies issues by CMS that identify specific medical items, svcs, trtmt procedures or technologies that can be covered and paid for the MC program. Updated quarterly. |
| Definitive vs. Non-Definitive LCD/NCD | Definitive: Lists specific dx codes, ICD-10 procedure codes and possibly signs and symptoms to support the need for the item or svc being given. Non-Definitive: provides potential coverage circumstances but usually does not specify coding. |
| What is an RVU and explain | Relative Value Unit - every medical procedure recognized by MC has been assigned units of value for various resources used to provide svcs. Takes into account: - Work required - Practice Expense - Malpractice Ins Expense |
| What does a Procedure Charge entail? | It should include: - cost of labor hours - cost of equipment being used (determined by dividing the cost o the equipment by the estimated number of procedures over the number of years the equipment should last. |
| What is Medicare Addendum B? | Quarterly release of charge updates to include status indicators that offer detail about that of each code. |
| List examples of status indicators on Medicare Addendum B: | C: IP Only D: Deleted Code N: Pd under OPPS as pmt is packaged into pmts of other svcs G or H: Pass through codes K: Non pass through codes for drugs separately payable by MC B,E or M: non covered, not payable but usually have an alternate code. |
| Who should be involved in a Charge Master Committee? | - HIM (Health Information Management) - Finance - Regulatory Affairs - Information Services - Supply Chain - Pharma - Dept Managers for the specific areas involved in the charge |
| After filling out the charge request form, what are the next steps to be taken by the CDM Dept? | Review request Assign CDM # for charging Set up charge Assign correct GL Group charges correctly on the UB Verify that CPT/HCPCS codes are appropriate Verify Rev Codes Work w/ facility reimbursement dept to validate Have CM committee review |
| What reimbursement tools can be used to establish charges? | - APC's (Ambulatory Payment Classifications) - Fee Schedules - MC Addendum B - MC IP Only procedural listing |
| What does a supply charge entail? | - Most not billed separately, included in the chrg for the procedure. - Some facilities have a minimum cost in order to set up a separate supply charge. - Supply chrgs associated with a specific trmt shld be reviewed as an established supply charge. |
Created by:
Amy17349
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