Chargemaster Maintenance: Correct, Complete, and Compliant Coding

By Vicki Fry, MS, MBA
To simplify chargemaster maintenance let’s focus on three key issues in each hospital department: correct, complete, and compliant coding (aka the three Cs). Periodic chargemaster reviews systematically verify that the correct HCPCS Level II and CPT® codes are assigned to each line-item, they make sure the departments have a complete array of codes to report all services provided and that all chargemaster line-items are compliantly reported to assure accuracy and reduce the effort necessary for maintenance.

First C: Correct Codes

Understanding what service, procedure, or supply/pharmaceutical is provided when a line-item is charged to a patient is the first step to ensure the correct codes are assigned for each chargemaster line-item. Since many departments use chargetickets or electronic charge entry to record services mapped to a chargemaster procedure number, interviewing staff and reviewing chargetickets/charge entry software mapping is a necessary first step. It’s very common to find inaccuracies between what a department is capturing on their chargeticket and what is being reported on a chargemaster. For example, when therapeutic infusions on a chargeticket are mapped to hydration codes on the chargemaster, or bilateral imaging procedures are mapped to unilateral procedures. Each inconsistency between the chargeticket and the chargemaster must be corrected by either changing the department’s document and/or software or the chargemaster.
After verifying the appropriateness of each chargemaster line-item description for the service, determine if the correct HCPCS Level II, CPT® and revenue code is present. To do so:

• Change codes that do not accurately
• represent the service provided
• Add codes for all line-items that should be reported with a CPT®/HCPCS code
• Determine if hard-coded modifiers are needed
• Scrutinize “unlisted” code line-items
• Remove codes from line-items that are coded by HIM

Common correct code errors to look for are:

• Missing or inaccurate modifiers for radiology, physical/occupational/speech therapy, and other procedures
• Assigning an unlisted HCPCS code when a specific code is available
• Missing HCPCS codes for pharmaceuticals that are separately paid
• Missing HCPCS C codes for devices that have associated CMS device/procedure edits
• Assigning an inappropriate supply/device C code
• Assigning a CPT® code when an alternate HCPCS code is necessary for Medicare billing
• Assigning a deleted or non-billable HCPCS code

Second C: Complete Codes

To review for complete codes make sure each department has sufficient chargemaster line-items to capture all of the services, procedures, or supply/pharmaceuticals provided to their patients. Frequently, departments do not charge for all services rendered because they are not aware of the proper use or availability of HCPCS codes. You can determine if departments have the complete ranges of chargemaster codes and line-items by:

• Understanding what services are provided
• Asking department staff if they provide services they either don’t charge for or don’t have an appropriate line-item to use to report the service
• Reviewing new codes with staff to determine if they should be added to the chargemaster
• Checking what applicable codes are not on the chargemaster and asking if they should be included
• Using this process improves complete coding by identifying when, for example, missing E/M levels of care, infusion codes, contrast and radiopharmaceuticals, add-on codes, etc. should be added to departments’ chargemasters.
• For a complete code review, you should verify that chargemaster and chargeticket line-items accurately describe the unit being captured. Each unit-specific code line-items such as add-on codes, anatomy codes, time or age-specific codes, pharmaceutical dose codes, should identify the accurate billing unit in the description. Include descriptors such as “EA ADD,” “BIL,” “PER ML,” etc. to increase accuracy and charge capture.

Common complete code errors to look for are:

• Missing E/M Level of Care codes
• Missing observation codes
• Missing drug administration (injection/infusion) codes
• Missing or inappropriate use of add-on codes
• Missing radiology contrast and radiopharmaceutical codes
• Missing codes for procedures reported with more than one HCPCS code (i.e., S&I code with missing associated injection code)
• Missing or inaccurate unit in pharmaceutical description

Third C: Compliant Codes

The final issue in reviewing and maintaining chargemasters is to assure all codes are compliant with coding conventions and federal, state and other third-party payer rules and regulations. Reviewing for compliant codes includes confirming that chargemaster line-items are both used and reported consistent with rules. The best way to accomplish compliant code is to interview department staff for verification. Ask the staff specific questions concerning compliant service code use to determine their general compliance knowledge and adherence. Regular compliance communication and education is also advisable. At a minimum, compliance education should include the following:

• Coding conventions, bundling/unbundling rules, CCI edits, OCE edits
• Medicare, Medicaid, and other state regulations and coverage rules
• FI-specific requirements
• Documentation requirements
• Licensure billing requirements
• Corporate compliance guidance/rules (if applicable)

Next, the chargemaster should be reviewed to identify, modify or remove line-items that should not be reported separately or are being inaccurately reported. This review should include the following:

• Identifying all routine supplies that are not separately billable
• Assuring all line-items that include supplies with descriptors that include kit, tray, set, etc. are only billing for separately billable contents and all contents are documented
• Making sure self-administrable drugs have appropriate revenue codes
• Checking commonly unbundled codes and/or separate procedure codes for appropriateness
• Verifying method-specific laboratory codes are described appropriately laboratory panels are not unbundled, “miscellaneous” line-items are used judiciously, etc.)
• Discussing noncompliant line-items and modifications or removal with department managers prior to action

Common compliant code errors to look for are:

• Inaccurate Pharmacy HCPCS code assignment
• Inaccurate revenue code assignment on non-injectable drugs
• Inaccurate HCPCS and revenue code assignment on FI-designated Self Administrable Drugs (SAD)
• Inappropriate reporting of routine supplies
• Inappropriate reporting of equipment
• Excessive use of “miscellaneous” line-items when service specific line-items should be developed

Ongoing Chargemaster Maintenance

Focusing on correct, complete, and compliant coding in reviewing department chargemasters streamlines the ongoing chargemaster maintenance. Ultimately, maintenance results in all chargemaster issues being addressed and requiring less effort.

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