Date of Last Revised 09/03/10
SME: Director of Financial Operations
Before making changes to the charge master, it is important to establish that the revised codes, descriptors and fees comply with all relevant laws, regulations and standards, and that they accurately reflect the services provided and resources expended. This requires input and approval from the care provider(s), procedure coders, program administrators, managed care, compliance and reimbursement. Once changes are made, it is important to provide and document training for providers.
The Charge Master Revision Form will capture the code, coding system, description, program where the service will be provided (e.g. IP), the patients for whom the services will be provided (e.g. adolescent only), the clinicians who are licensed and privileged to provide the services, the reason for the change, and the fee schedule. Generally speaking the person who proposes the change should be responsible for seeing it through the approval process. Responsibility for charge master revisions depends on the reason for the change. See table below.
If: |
then, the responsible party is: |
a coverage policy mandates a change, for example, as communicated through a Medicare Program Terminal |
The Clinical Manager. |
a new inpatient service is to be offered, |
The chief of the clinical service that will provide the service. |
|
|
the change is to the fee schedule only, |
The Clinical Manager |
the change is to adjust the fee schedule to a reasonable and customary rate |
The Clinical Manager |
Adding New Codes
New services must meet the following criteria. They must be:
The clinician will verify that the service described is the one that will be provided Procedure coders will verify that the code is valid and apply a crosswalk, if necessary, to the CPT or CPT-4 code. Coders will also identify any modifiers which might apply to the new code, as well as any policies requiring bundling of the service. Managed Care will identify the plans which cover the service. Compliance will identify the federal programs which cover the service, and whether the benefit is for professional services or for a facility. Reimbursement will analyze cost data to assign a relative value unit and to calculate a fee schedule, in addition to identifying an appropriate revenue code.
Modifying Existing Codes
The person requesting the change must provide the reason for the change (e.g. discontinuation of a program or service), providing documentation for the change in policy or circumstances.
Certifications
At the end of the review process, each member of the review team will certify as follows:
Clinical Services:
__________ are clinically privileged/licensed to provide _________________ to adult/child/adolescent patients.
Program administrator
__________ may be performed/provided under the inpatient/outpatient/IOP/PHP program.
Coding:
CPT Code ____________ is the most accurate, valid code for _______________ (the proposed service)
Managed Care:
CPT Code _____________ may be provided, unbundled
Compliance:
__________ is / is not covered under Medicare Part ______
__________ is / is not covered under (straight) Medicaid ______
Reimbursement:
The Medicare fee schedule (CPT or APC) for _________ is _____________
The revenue code for ________ is ____________ if provided on an inpatient basis
The revenue code for ________ is ____________ if provided on an outpatient basis
The Joint Commission : Leadership