Charge Management Assessment
Charge Management Assessment
Charge Management teams can apply common risk management concepts for assessing their organizational charge management. In general, there are four basic phases for ensuring success when using assessments.
As reflected in the basic risk management process chart above, this includes:
- Identifying data and procedural risk
- Performing reviews to assess and quantify the level of risk
- Applying controls to reduce risk
- Monitoring effectiveness of the controls through periodic evaluations
To support the risk assessment process above, we commonly share our Organizational Charge Management Assessment in H&A consulting and educational programs. Teams revisit this assessment periodically to see where they have improved and where process gaps or risk still exist.
Organizational Charge Management Assessment
Scoring key: 1 – Never 2 – Seldom 3 – Sometimes 4 – Usually 5 – Always
- 1. All necessary Charge Master and charge data updates are performed no later than their effective dates for CMS and other payers.
- 2. Key members of the Hospital Administrative/Executive Team are kept informed of high-level topics pertinent to charge data and the Charge Master file (e.g. accuracy of CDM content, compliance concerns about specific charges, audit findings, pricing issues/concerns, etc.).
- 3. Key members of the Hospital Administrative/Executive Team are updated on the status of significant Charge Master and charge data management tasks and projects (e.g. annual update work, system conversion masterfile development, CDM Review project implementation, etc.).
- 4. Guidance related to Charge Master or organizational charging rules are incorporated into the facility’s compliance guidelines, hospital policies, hospital procedures, or other approved charge protocol documents.
- 5. Detailed policies or protocol are available to identify internal systems and processes for CPT and HCPCS code assignment and overrides (e.g. HIM/Medical Record Department ‘soft’ or ‘manual’ coding, Charge Master ‘hard coding’, or coding/charging from other systems or personnel).
- 6. Correct Coding Initiative (CCI) and Medically Unlikely Edit (MUE) guidelines are available to all departments with CPT coding in their CDM and referenced when claims edit errors occur. Lost charges, late charges, and errors in charge capture are identified through a daily reconciliation process of department statistics and system reports for the hospital’s major ancillary departments.
- 7. Department representatives are held accountable for maintaining their sections of the Charge Master file.
- 8. Department representatives are aware of the priority regulatory and coding information they should be reviewing at least quarterly for Charge Master maintenance including information published in Medicare guidelines and Coding Guidelines (HCPCS references, CPT-4 references, and any applicable payer-specific coding references that vary from current CPT/HCPCS codes).
- 9. Regulatory, Charge Master, coding, payment system updates, and charge compliance references are distributed to appropriate Health System personnel members including (Medicare transmittals, priority Federal Register Final Rules, Medicare Manuals, and CPT/HCPCS coding information).
- 10. Clinical and technical department representatives have access to current reference information for their charges including CPT/HCPCS resources, payment rates, OPPS/MPFS Status Indicators, applicable OCE Edits, Payment/Pricing Indicators, Relative Value Units (if applicable).
- 11. All assigned department representatives participate in review and verification of all necessary Charge Master (and other associated file) updates relative to changes in regulations, payment system changes, or codes.
- 12. Errors with CPT/HCPCS, modifiers, revenue codes, units of service, and price identified by billing staff are accurately revised and documented/communicated for Charge Master or charge capture corrective action.
- 13. The Charge Master Coordinator or Team has/have current documentation of all system edits or overrides that change Charge Master data on claims (billing software, claims edits, etc.).
- 15. All interfaced and ancillary information system applications that ‘drive’ or impact charge information (codes, charge entry, pricing, multiplier/divisors, etc.) are routinely audited against Charge Master data to ensure synchronization.
- 16. Inactive charges and cost centers are routinely identified within the Charge Master file; and deactivation/inactivation is performed when appropriate.
- 17. New charge items are proactively researched for coverage, payment amounts, coding, and regulatory rules.
- 18. CDM Management owners have access to credible resources (internal or external) for challenges, problems or questions about reimbursement, payment system regulations, charging protocol, and coding rules.
- 19. Pricing-setting policies are documented for room & board, supplies, drugs, ancillary tests, outpatient procedures, and other billable services.
- 20. Charge Descriptions and description abbreviations are sufficiently clear to allow auditing against the assigned Charge Master codes and correlation with their counterpart records in ancillary masterfiles.
Points Grade 100-95 A The Health System appears to be doing a very good job developing and managing charge data and processes. 94-85 B The Health System has developed and complies with many Charge Management requirements. However, there is room for improvement. 84-75 C The Health System has initiated many key charge management concepts, but needs to expand its efforts. 74-65 D The Health System has several key elements of an effective Charge Management program, but there is significant need for improvement. Potential for compliance and revenue risks may exist. < 65 NI Needs Improvement – Your hospital is at high risk for lost reimbursement and compliance problems associated with what appears to be inadequate Charge Management.
Reference and Related Posts:
10 Steps for Failsafe Charge Data Management – Holliday & Associates
Holliday & Associates Charge Management Software Solutions
ChargeAssist HFMA Peer Review Renewal Press Release
ChargeAssist Charge Master Public Portal Press Release
Holliday & Associates offers ChargeAssist®; an HFMA Peer Reviewed® Charge Master auditing and resource tool for easily auditing, collaborating, and maintaining Charge Master files. We also provide Charge Management Team and Charge Master Coordinator Educational Programs as well as customized CDM Reviews by a team of credentialed clinical, coding and technical auditors.
Visit Holliday & Associates web page for details on software functions and consulting services here: https://www.chargeassist.com/chargeassist/
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Details on HFMA Peer Review® – ChargeAssist® HFMA Peer Review Renewal Press Release