Essential Elements of Charge Protection Language

Sponsored by Cleverley + Associates

 

The chargemaster, or CDM (charge description master), is an integral component of hospital financial strategy, reimbursement, and the revenue cycle. It is important to understand the complexities of the CDM as well as the consequences of even seemingly simple changes.

Throughout the year, this “menu” of hospital service prices changes to reflect minor adjustments. Larger modifications are typically implemented at least once a year to maintain policy changes and stay competitive in an ever changing healthcare market. While raising prices can appear to lead to higher payments from managed care payers, charge increase limitations are often negotiated to prevent sizeable payment increases.

The limit percent itself as well as how the payer evaluates the change to charges determines how restrictive a limit will be. Limits can range from a fully restrictive 0 percent upward to as high as 9% in some cases, with a usual average of around 4 to 5 percent. The percent can be defined in the contract, or tied to a published amount – typically some component of the consumer price index (CPI).

An increase to the chargemaster can have a different impact on contract terms depending on how the payer evaluates the charge increase. Though many payers evaluate the overall change to the chargemaster, other methods can be used. A few of the most common are as follows.

• Overall change to health plan’s patient mix
• Overall change reported separately for inpatient and outpatient services
• Overall change reported for services paid a percent of charge

Multiple departments, including managed care, chargemaster, and finance should work together to align financial strategies with knowledge of how managed care contract language plays into the bottom line. It is critical for hospitals to understand how limits are determined, as well as how health plans are evaluating reported charge adjustments. Understanding these components can help hospitals evaluate net revenue impacts that are the result of charge adjustments while remaining in line with financial goals.

About the Author

Laura Jacobson, RHIA, has over 10 years of experience working with third party payer contractual arrangements as a consultant at Cleverley and Associates. She earned her bachelor’s degree in Health Information Management and Systems from The Ohio State University and holds a RHIA certification from AHIMA.

Editor’s note: This article is originally from Essential Elements of Charge Protection Language.

Article reprinted with permission.  

Coding for Dialysis

This month, “Spotlight on CPT” presents information regarding the coding for dialysis. As coding professionals know, dialysis is a treatment that removes waste, fluids, and toxins from the blood when the patient’s own kidneys do not function properly. This procedure is most often performed when patients have end-stage renal disease (ESRD) when dialysis is done three times a week, but can also be used when patients suffer from an acute kidney injury (AKI) and need assistance for a short time period.

Dialysis can be performed in one of two ways: either hemodialysis or peritoneal dialysis. Hemodialysis is performed at a dialysis center or at home, while peritoneal dialysis is performed at home. Hemodialysis will require an arteriovenous fistula, graft, or catheter inserted in the chest. Peritoneal dialysis requires a catheter being inserted into the abdominal region.

Source: https://cfkc.org/post/hemodialysis-vs-peritoneal-dialysis-which-is-right-for-you

 

The Medicine section of CPT houses the codes for dialysis. Inpatient hemodialysis for ESRD and non-ESRD patients is captured with either code 90935 or 90937. These codes apply to outpatients having non-ESRD treatment. The difference between the codes is related to the frequency of physician or other qualified healthcare professional (QHP) evaluation of the patient. If there is a single evaluation, code 90935 should be assigned. If, however, repeated evaluation(s) are necessary, whether or not there is any change made to the dialysis prescription, then code 90937 is assigned. If a non-physician healthcare professional provides a home visit for a hemodialysis, a note in the CPT manual directs coding professionals to assign 99512. When using code 99512, the term “home” can mean the patient’s own home, assisted living, a group home, a custodial care facility, a school, or a nontraditional private home.

There are two codes that could be assigned for dialysis administered in a method other than hemodialysis. Those methodologies include peritoneal dialysis, hemofiltration, or other continuous renal replacement therapy. As with the hemodialysis codes, the two codes available for the “other” dialysis are also distinguished by how many evaluations are performed. A single evaluation is coded to 90945, and if repeated evaluations are necessary, the proper code is 90947. If a non-physician healthcare professional provides home infusion for peritoneal dialysis code 99601 is assigned per visit for up to two hours. Any additional hours of infusion can be reported by using add-on code 99602.

Also in the Medicine section are codes for end-stage renal disease services that are provided in an outpatient setting. There are three levels of service which are billed once per month (month equates to 30 days per CPT). The levels are distinguished by the number of face-to-face visits between the patient and provider. The levels are:

• 4 or more face-to-face visits
• 2-3 face-to-face visits
• 1 face-to-face visit

Each level is then broken down by age group. Those groupings are:

• Under age 2
• Ages 2-11
• Ages 12-19
• Ages 20 and older

One set of codes, 90951-90962, is for assignment when the patient is in an outpatient setting. The other set of codes, 90963-90966 are assigned for home dialysis patients. 

Another set of codes, 90967-90970, is for patients that have received dialysis services for less than a month and under the following circumstances:

• The patient was transient
• Partial month with at least one face-to-face visit, but without a complete assessment (When a complete assessment has been done during the month, but there is less than a full month of services, it is appropriate to use the full month codes, as appropriate, from 90951-90962)
• Patient hospitalized before complete assessment was done
• Patient experienced recovery or death
• Patient received a transplant

An important note about codes 90967-90970 is that they should be assigned per day, not just once for the partial month.

Now, light has been shed on coding dialysis.

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About the Author 

Dianna Foley, RHIA, CHPS, CCS, CDIP, is an HIM professional with over 25 years of experience.  She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA, along with being an AHIMA-approved ICD-10-CM/PCS trainer.  Dianna has held many positions in HIM and is now an independent coding consultant.  She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna is an AHIMA-published author and has volunteered with AHIMA on projects including certification item writing, certification exam development, coding rapid design, and most recently has served on AHIMA’s nominating committee.  She is a presenter on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.