Chargemaster can be key job niche for HIM pros

Staff need to take Chargemaster 101’

As HIM professional needs evolve due to the changing health care industry and reimbursement issues, experts say the role of coders also must progress to more than a job that merely requires someone to assign a code.

"They must get involved with billing issues and the Chargemaster," says Glenda Schuler, RHIT, senior consultant for Ingenix/St. Anthony Consulting in Salt Lake City.

Schuler and Jill Giddens, RHIA, CCS, a technical editor with Ingenix Publishing in Salt Lake City, educate coders about the Chargemaster, its basic data elements, and the UB92 forms, so they can apply this knowledge to their jobs within a hospital system.

They teach coders what they need to do to bring themselves up to speed with the Chargemaster terminology, resources, and references. Schuler and Giddens offer these descriptions of some of the more common problem areas involving Chargemasters and coding:

Respiratory services: Historically, Medicare has defined respiratory care as an area that often does not require the skills of a respiratory therapist, Schuler notes. "And, in fact, RNs can perform many of these procedures."

The result is that respiratory therapists cannot bill for those services and neither can the nursing staff, Schuler adds. "It’s part of routine standard patient care."

This is why hospitals need to monitor the respiratory Chargemaster to ensure only the appropriate services are compliantly reported, Schuler explains. 

In the past, hospital respiratory therapists have been creative in procedure descriptions for services they are providing, Schuler says. "Medicare expects that most of these services are not billable and that nursing can provide them, so those extra charge lines must be eliminated from the Chargemaster and cannot be charged."

Radiology services: This is another area that should be scrutinized closely on the Chargemaster, Schuler says.

"There are about 44 CPT codes reported by radiology departments that should have a surgical code reported with them," Schuler says. "It’s a one-to-one correlation."

For example, if a clinician has done a shoulder arthrogram and had to inject contrast media into the shoulder to be able to visualize the joint, then there should be an injection CPT code to accompany that arthrogram code, Schuler says.

There are more complex examples for angiography codes, including CPT codes that could be reported for surgical codes and that are not used one-to-one. Instead, they are reported based on the procedure performed, Schuler says.

"This is where coders come in to play, where they will use documentation in the chart to determine an appropriate CPT code," Schuler adds.

This is one of the more confusing areas of radiology coding, and coders need training to do this right, Schuler and Giddens say.

"A lot of times, a hospital doesn’t have a trained coder applying codes for technical/surgical portion of the chart," Giddens says. "Sometimes documentation is not as thorough as it needs to be for the coders to assign them."

What might occur is that the person assigned to do the coding has the technical expertise but doesn’t understand the billing/coding end of the business, Schuler adds. "That’s where you have the opportunity as a coder to help them."

For example, in some larger institutions, there might be a certified coder who works only in the radiology department and is able to focus on finding the correct code for a particular procedure after reviewing the documentation, Schuler says.

"In smaller facilities they will have these codes in the Chargemaster, and sometimes the radiology technicians need to be taught how to report these other components, procedures," Schuler says.

Make sure surgical component is reported

For example, in the case of an interventional radiology procedure where an injection occurred during a venogram, the physician should document in the report where the injection of contrast media occurred or where the catheter is placed, Schuler explains.

"Anatomy is important here," Schuler adds. "You need clear and distinct documentation of where the catheter was placed, and often the coder doesn’t have this information."

There is a variety of ways to report the individual CPT codes in the Chargemaster, and the radiology technician sometimes will select the code or codes that reflect the entire surgical component, Schuler says.

"The important thing here is that the surgical component gets reported on the claim and is supported by documentation from the physician," Schuler says.

But what might occur is that the technicians who attended the procedure will select a CPT code based on what they saw, and the doctor will later dictate the documentation but will leave off the vital information that would support the CPT code that already has been selected, Giddens explains.

This is why the coding department needs to wait until the documentation returns and then compare it with the Chargemaster coding to make sure it’s correct so it can be validated as correct based on the physician’s documentation, Schuler says.

"That’s where hospitals are struggling, because coders are becoming more and more difficult to find," Schuler adds.

Without a trained coder reviewing the Chargemaster to look for errors and discrepancies, the hospital may have a problem with payers when charts are audited.

Training specialty coders: Some hospitals are solving this problem by hiring and training coders to specialize in specific areas, such as radiology, Giddens says.

"One company in Atlanta is hiring its own coders and taking them through rigorous training with a clinical person who specializes in radiology," Giddens says. "So the coders understand the clinical side of interventional radiology."

This type of clinical education can be very important, and it can help a health institution build its business, she says.

Certified coders are very important for a health facility’s compliance with regulations because proper reimbursement is essential to avoiding fraud and abuse problems.

Of course, the problem is that finding quality coders is more difficult and has led hospitals to offer sign-on bonuses, Schuler says.

Unfortunately, what sometimes happens at health care facilities that are short of coders is that the documentation is not reviewed and items are billed according to what the clinical staff has sent through on the Chargemaster, Giddens says.

When coders who are knowledgeable about clinical care are able to review the documentation, there may be an addendum added to the documentation to reflect the specific details that are needed to justify a particular code, Giddens says.

Without this expertise, knowledge, and attention, there could be inappropriate billing, Giddens adds.

All it takes is one wrong CPT code to result in a facility being either overpaid or underpaid for a service, Schuler says.

Check-off sheets as back-up: When a hospital is unable to have coders with a particular expertise, an alternative might be to have clinical technicians use check-off sheets that list the various procedures and details that must be documented for coding to be done accurately, Schuler suggests.

"Physicians must document that the procedure was done, but a check-off sheet is a tool that can prompt or remind a physician of what was done and what needs to be documented," Schuler says. "Technicians might use the check-off form, and the physician will review the check-off chart prior to dictating notes, so it’s a reminder of what was done and how not to forget to include it in the documentation."

This can save considerable time, says Schuler. If incomplete documentation were to reach the coder, he or she would have to track down the physician and ask for the additional information.

Assigning codes based on incomplete documentation would be worse.

"It’s really important to have all procedures documented," Schuler adds.