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Be proactive, not reactive to the Quarterly Provider Updates (QPU).
Once a quarter, changes being proposed and made to programs administered by CMS are published to providers. This QPU process is intended to serve as a predictable means by which providers can analyze updates and incorporate changes to their billing systems and charging practices. Since the QPU changes often impact the chargemaster, timely updates are required to avoid adverse effects to provider reimbursement.
MedCom recommends specific actions immediately following CMS's release of QPU.
With each QPU release, new reference files are published that include the latest program changes:
- Addendum B - Published by CMS; contains payment rates and status indicators for valid codes under OPPS
- CPT4 - Published by the AMA; contains a complete listing of valid CPT codes and descriptions.
- HCPCS Level II - Published by CMS; contains a complete listing of valid HCPCS Level II codes and descriptions.
Through a series of electronic queries, providers can quickly compare new and old files in order to isolate program changes and determine the impact to billing systems and charging practices. At minimum, MedCom recommends that providers identify each of the following:
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Codes Added
By combining the CPT4 and HCPCS Level II files, providers can get a complete listing of valid codes with descriptions. An electronic query can quickly isolate which codes have been added as a comparison to the previous quarter's file. Providers should analyze this subset of codes to determine which services are performed in their facility, and then identify the appropriate departments where coding updates are required in the chargemaster. A follow-up education session with the appropriate charge capture personnel will ensure that the provider is correctly billing for all services rendered.
Codes Deleted
Converse to the query for codes added, the same reference files can be used to isolate which codes have been deleted. Providers should also analyze this subset of codes to determine if changes are required in the chargemaster, and follow up with the charge capture personnel to understand how to appropriately bill for services going forward. With the elimination of the grace period in FY2006, timely updates for ensuring that deleted codes have been addressed are more important than ever.
Description Changes
Identifying codes with description changes can provide valuable insight into how services should be billed. Using the same electronic technique of comparing the new and old CPT4/HCPCS file, providers can quickly identify codes with description updates. In addition to possible chargemaster revisions, description changes (such as billing unit updates) can significantly impact how services are billed and reimbursed.
In the example below from the 2007 January updates, the description of CPT code 90761 was revised to remove the time limitation of "up to 8 hours":
FY2006: Intravenous infusion, hydration; each additional hour, up to 8 hours
FY2007: Intravenous infusion, hydration; each additional hour
This description change reflects a revised policy by CMS, which now plans to reimburse providers for infusion services extending beyond eight hours. Charge capture personnel should be notified that patients can now be charged for infusions extending beyond the previous constraint. In addition to the obvious description update in the chargemaster, there may be a billing edit in place preventing outgoing claims from exceeding a maximum charge for this code, so additional follow-up should be done to remove any of this system logic.
Status Indicator Changes
The Payment Status Indicators that appear on Addendum B specify how codes are reimbursed by Medicare. An explanation of each Status Indicator is provided on Medicare's Addendum D. An electronic query of Addendum B to identify codes with status indicator changes is another important step in the QPU process. A change in Status Indicator may impact how a provider bills for service, and should be addressed with due diligence.
In the example below from the 2007 January updates, the Status Indicator of HCPCS code A9539 was revised from N to H:
FY2006: N - Items and services packaged into APC rates
FY2007: H - Separate cost-based pass-through payment
This radiopharmaceutical, which was previously not paid separately, should now be charged at a rate equivalent to the drug cost divided by the hospital's ratio of costs-to-charges (RCC), in order to capture appropriate reimbursement.
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If this process seems daunting, MedCom Solutions can help.
The examples above represent a sampling of the most frequent types of quarterly updates that impact provider chargemaster management and charge capture processes. Contact MedCom Solutions for a comprehensive review of your facility's response to the January 2007 QPU.
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