Access department's CDM analyst is ‘next step' to ensure clean claim
Access department's CDM analyst is ‘next step' to ensure clean claim
UPMC targets unbilled accounts worth millions
A newly created position at the University of Pennsylvania Medical Center-Presbyterian in Philadelphia is helping the access department take "that next step" toward reducing denials and ensuring proper reimbursement, says Raina Harrell, CHAM, director of patient access for business operations.
The "charge description master [CDM] analyst" position came about, Harrell adds, after the patient access department started working more closely with patient accounting to determine the reason behind a large number of reimbursement denials and rejections.
It became clear that, in many cases, accounts were being denied despite the fact that access personnel were doing everything right, she says, and that the problem was costing the hospital millions of dollars.
"We realized a lot of the rejections were secondary to the fact that we had issues in our CDM, which houses all of the charge codes and charges," Harrell explains. "When we bill, we have to make sure we use the appropriate codes, so we have software in place that flags the account and lets us know we won't get paid because a code is missing or [the account] is otherwise not up to the standards the payer will look for."
The codes change over time as the result of changes in government regulations and new services that need to be added, Harrell notes. "Many of the denials and rejections we were getting back were related to the CDM."
It's a given that the CDM should be examined at least every October, when the Centers for Medicare & Medicaid Services (CMS) updates the way that providers bill and what they need to bill for, she says, but there are also changes throughout the year — for example, when a new procedure is added.
When the hospital did an analysis of the accounts rejected by the software — or "claims scrubber" — that had not billed because of some type of revenue code or common procedure code (CPC) problem, Harrell says, it found a variety of CDM-related issues.
Revenue codes, she notes, are three-digit codes that providers use to describe provided services. "When completing the UB-92 [billing form], providers must describe the services related to the revenue code used." The CPC codes, Harrell adds, describe provided services, and are divided by CMS into three levels — physician services, non-physician services and supplies, and local codes assigned by local carriers and intermediaries when no national codes have been assigned for allowed services.
Among the unbilled accounts related to CDM issues were, for example, bills for a new service the radiology department had begun the year before, for which the codes had not been entered properly, she explains. "We fixed it, rebuilt those accounts, but we realized that as this happens in daily operations, we needed somebody on top of it.
"We looked at our open accounts receivable, and saw what was sitting there — more than 1,500 accounts, worth millions of dollars, waiting for fixes," Harrell says. "When we started to quantify [the problem] with our patient accounting department we said, ‘This is not just a cleanup that needs to occur; this is something ongoing that needs to be done, or we will be in the same position a year from now.'"
The decision was made to create a new position, and to have that position lie within patient access, she says, "because we are the one department that connects with every other department in the hospital — radiology, laboratory, physical therapy — and we have responsibility for medical records."
A systems analyst in the access department was assigned to begin the CDM cleanup while Harrell and the rest of the access management team put together return on investment (ROI) projections for the new job, she notes. "In January 2005, we recognized there was a problem and started working on it, and by February, we knew there were CDM issues.
"We identified the problem in May, but we were so close to [the end of the fiscal year] that we put the position in the July budget."
There were some 1,500 CDM-related inpatient and outpatient unbilled accounts in January, Harrell notes, and by June, the number had dropped to less than 500 through the efforts of the system analyst. (See graph, below.) "By April, we knew we needed a full-time person focused on the issue and would include the position in our budget [request]."
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Using the 1,500 unbilled accounts, and the dramatic drop after the system analyst's intervention, she says, the access management team was able to put together an impressive ROI for the chief financial officer and other hospital administrators.
In addition to the one-time cleanup, Harrell adds, "we feel that 30% of what is out there [are problems] that will happen annually, so [the new employee] can make sure they don't happen every single year."
While the funding for the new position was approved in July, it was late November before the access management team found the right person for the job and brought him on board, she says. The challenge, Harrell explains, was that the CDM analyst needed to have an understanding of billing and medical records coding, as well as some ancillary hospital experience.
"This person needs to be able to communicate with laboratory and radiology staff, and see things from their perspective," she notes. "He has to make [ancillary staff] understand that it has to do with their reimbursement, so he needs communication skills.
"Another part of what this person will do," Harrell adds, "is to work with administrators and say, ‘This is what your CDM looks like now. Are you still performing all of these services? Is this the charge that should be associated with this service?' We're trying to do this preventively as well."
A certain amount of information systems knowledge is also required, she points out, because the person needs to understand how different parts of the computer system work and interact. "Sometimes there is a problem there."
After some fine-tuning of the job description so that it was "very specific as to what we were looking for," Harrell says, the position was posted internally on the health system's web site.
During the cleanup by the systems analyst, meanwhile, the identification of one issue in some cases cleared multiple accounts, Harrell notes, as with the new radiology service that had not been entered into the CDM.
Another example of "low-hanging fruit," she adds, had to do with charges that were entered late, so that the bill would drop before they were put on the account, resulting in a rejection.
Later in the process, there were "a lot of onesie, twosie issues," where the fix was a bit more complex, Harrell says. "It might be looking at, ‘Did the operating room not enter a charge on the account?' or ‘Did the person enter the charge on the wrong account?' The charge for the surgery is there, but the OR charge is not. Two cases might be missing a portion of a charge, but until someone looked at that account, it would sit there.
"For every procedure charge, there needs to be an OR charge, and vice versa," she notes, "and if the bill is missing one or the other, the [claims scrubber] will kick it out. Someone has to look and see what the problem is, and fix it."
The dollar value on each unbilled account ranged from $100 to $50,000, Harrell says. "We could have [a bill] sitting out there from oncology for a chemotherapy service that was rejected because there was a drug charge, but no indication how the drug was administered. The mechanism for getting the drug is not on there."
Drew Elliott, the person who was finally hired as CDM analyst, Harrell says, came from the hospital's billing department, where as part of his job, he had looked at Medicare rejections. He had started work at the hospital years before in a clerical position, had entered charges in the past, and was familiar with all of the ancillary departments, she adds.
"He has the skills, and is already making hits for us [the first week on the job]," Harrell says. "Coming from patient accounting, he is better able to understand the comments from billers that were in the accounts, and go right to the departments and talk about what the problems were."
"In billing," Elliott notes, "I was looking at revenue codes and CPC codes — what was given to me — and now I have the opportunity to clarify what's given to billing. It's interesting looking at it from another perspective."
Once the CDM cleanup is complete, he says he will take a more proactive role — making note of new codes and updates and bringing them to the attention of ancillary departments "so we don't have to go back and forth with patient accounting."
"If there is a problem with a charge entered," Harrell points out, "he can go back and say, ‘We had 10 accounts that didn't get an OR charge. How can we prevent this?' If radiology is doing a new procedure, [staff] will call Drew and say, ‘Can you help us enter this new charge correctly?'"
It's particularly frustrating, she says, when access personnel "have jumped through all the hoops — preregistration, registration, precertification, insurance verification, copay all done properly — and somebody won't pay for it. So he can take that next step for us."
[Editor's note: Raina Harrell can be reached at (215) 662-9295 or [email protected].]
A newly created position at the University of Pennsylvania Medical Center-Presbyterian in Philadelphia is helping the access department take "that next step" toward reducing denials and ensuring proper reimbursement, says Raina Harrell, CHAM, director of patient access for business operations.Subscribe Now for Access
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