CDM Review

Stage One Overview

The general scope of these reviews encompass a complete comprehensive review of the Charge Description Master (CDM), including: Usage, Description, Revenue Code assignment, CPT/HCPC code assignment, Modifier assignment and Pricing as well as a complete review of all subsystems that interrelate with the CDM.

Stage Two CDM Review Methodology

Each departmental session starts with full introduction of the layout of each of the three MedCompliance Services Editors that are in an Excel format. The next step is a review with each department director and staff of every CDM line in their department for accuracy, compliance and revenue opportunities. At the end of each session the department director is emailed a copy of the editor's results and findings as analyzed and discussed for their respective department.

The CDM review will accomplish the following objectives

• Review CDM for Description Issues
  • Validate all existing Descriptions in CDM is correctly identifying procedure, service, device and drug.
  • Identify all items with missing Descriptions.
  • Determine if the same Description is used more than once in CDM.
  • Identify all Descriptions that start with a number or a space.
  • Identify Descriptions that contain words such as "miscellaneous" or "other" for possible inactivation
• Review CDM for correct UB Revenue coding
  • Validate all existing Revenue Codes in CDM are correctly assigned.
  • Identify all items with missing Revenue Codes.
  • Determine the validity and accuracy of Revenue Codes to listed item descriptions.
  • Determine the validity, accuracy, and alignment of the Revenue Codes to listed CPT/HCPCS codes.
  • Review all items with professional component, patient convenience, and "statistics" Revenue Codes for accuracy and validity.
• Review CDM for correct CPT/HCPC coding
  • Validate all existing CPT/HCPC codes in CDM are correctly assigned.
  • Identify all items with missing CPT/HCPCS codes.
  • Review all same CPT/HCPC coded item for uniformity in description.
  • Review the validity and accuracy of the CPT/HCPCS codes to listed item description.
  • Evaluate all relevant CPT/HCPC and Revenue Code combinations for each clinical department such as "panels/explosions" used for compliance with regulations.
  • Review and add all missing CPT/HCPC codes that have assigned Revenue Code 275 - Pacemaker, 276 - Intraocular Lens, 278 - Implant and 636 - Drugs requiring detailed coding.
  • Evaluate all CPT/HCPC coded drugs and radiopharmaceutical agents for dosage and multiplier compliance
  • Provide recommendations for missing reimbursable CPT/HCPC codes.
• Review CDM for Modifier issues
  • Validate all existing Modifiers in CDM are correctly assigned.
  • Review how Modifiers are assigned/selected and the rules of assignment.
  • Discuss benefits to assigning Modifiers in CDM instead of by HIM.
  • Identify all items with required Modifiers that are missing.
  • Determine if assigned Modifier is accurate.
• Perform Usage evaluation
  • Identify all items in CDM with no Usage for past two FY's for possible inactivation or if charges have been misapplied.
  • Review all CDM lines items with Usage is reasonable and accurately stated.
• Perform Status Indicator Code (SIC) evaluation
  • Identify all non-reimbursable items in CDM with SIC "B, C, E, M., N, Y"
  • Review each non-reimbursable SIC code for possible CPT/HCPC code replacement or removal of CPT/HCPC code.
• Perform basic Pricing evaluation
  • Identify and review all zero Priced items.
  • Identify and review all Prices less than established CMS (Medicare & Medicaid) fee schedules and APC Addendums A & B.
  • Identify all like items, by description and/or CPT/HCPC codes with different prices.
  • Review all markup or cost methods used hospital as by applied to each CDM item and if accurately applied for Pricing.
  • Review is all Revenue Coded 999 items are zero priced.
• Perform RAC Alert evaluation
  • Review every RAC Alert as identified by editor.
  • Discuss what RAC Alert means and how to be prepared.
• Basic Reimbursement Education
  • Interview department managers to validate the accurate reflection of services currently rendered by their department through industry standard models.
  • Provide guidance in implementing a daily charge reconciliation program with ongoing chart reviews.
  • Identify any departments where an in-depth review for lost revenue opportunities exists.
  • Compare order entry systems and all sub-systems in relation to the CDM, to ensure accuracy and make recommendations for correction of descriptions as needed.
  • Provide hospital departments with reimbursement education assistance for procedural modeling and coding accuracy.
  • Train hospital department directors on the importance of accurate CDM maintenance and the regulations they must follow to stay in compliance with all Third Party Intermediaries.
  • Establish a process for reviewing and maintaining the CDM on an ongoing basis.
  • Provide a written report at the end of engagement with recommendations for improving the ongoing integrity and efficiency of the hospital's charging system with full documentation to support every recommendation.

Stage Three File Format

Your CDM will be processed through thousands of scenarios allowing us to determine each and every billing problem from descriptions to pricing. In order to perform this review, we require the following files.

• CDM
  • Column A - Dept #
  • Column B - Item #
  • Column C - CDM Description
  • Column D - Revenue Code
  • Column E - CPT/HCPC Code
  • Column F - Price
  • Column G - Modifier (if not attached to CPT/HCPC code)

• Usage by FY (need 2 FY's if available)
  • Column A - Item #
  • Column B - IP Usage each FY
  • Column C - OP Usage each FY

• Department Listing - (in Excel format)
  • Column A - Department #
  • Column B - Department Title

• Order Entry System - (in Excel format)
  • Column A - Item #
  • Column B - Order Entry Description

• Each Sub System - (in Excel format)
  • Column A - Item #
  • Column B - Sub System Description

Stage Four Three Day Onsite Work Plan

• Review is performed on-site at hospital
• Time required on site for interviews is 2, 3, 4 or more days depending on size of facility and size of CDM
• Each departmental director will be assigned a time, such as this 3 day on site example (see below).

CDM Departmental Meetings

• Day 1
  • 8:00 - 9:00
    Introduction Session
  • 9:00 - 10:30
    Pharmacy
  • 10:30 - 11:30
    Nursing
  • 11:30 - 12:30
    Lunch
  • 12:30 - 2:00
    Lab
  • 2:00 - 3:30
    Cardiology
  • 3:30 - 5:00
    Central Supply
• Day 2
  • 8:00 - 9:00
    Dietary
  • 9:00 - 10:30
    Radiology
  • 10:30 - 11:30
    Oncology
  • 11:30 - 12:30
    Lunch
  • 12:30 - 2:00
    Pulmonary/Respiratory
  • 2:00 - 3:30
    ER
  • 3:30 - 5:00
    PT, OT, ST
• Day 3
  • 8:00 - 9:00
    Anesthesia & RR
  • 9:00 - 10:30
    Clinics
  • 10:30 - 11:30
    Pulmonary/Respiratory
  • 11:30 - 12:30
    Lunch
  • 12:30 - 2:00
    Cardiac Cath Lab
  • 2:00 - 4:00
    Wrap Up session with Administration of findings