1. Review CDM for correct CPT/HCPC coding:

• Identify all items with missing CPT/HCPCS codes.
• Review the validity and accuracy of the CPT/HCPCS codes to listed item description.
• Evaluate all “panels / explosions” being used for compliance with regulations.
• Provide recommendations for missing reimbursable CPT/HCPC codes.
• Evaluate relevant CPT/HCPC and Revenue Code combinations for each clinical department.

2. Review CDM for correct UB92 Revenue coding:

• 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.
• Identify if correct revenue codes have been assigned to implants and other carve-outs to insure proper billing and reimbursement from managed care payers.
• Review all items with professional component, patient convenience, and “statistics” revenue codes for accuracy and validity.
  

3. Review CDM for Description Issues:

• Review all items with professional component, patient convenience, and “statistics” revenue codes for accuracy and validity.
• Identify all items with missing descriptions.
• Determine if the same description is used more than once in same department and in other departments.
• Identify all descriptions that start with a number or a space.

4. Review CDM for Modifier Issues:

• Identify all items with required modifiers that are missing.
• Determine if assigned modifier is accurate.

5. Identify all items that have no use over the past 24 month period for possible deletion.

6. Interview department managers to validate the accurate reflection of services currently rendered by their department through industry standard models.

7. Provide guidance in implementing regulatory compliance standards.

8. Provide guidance in implementing charge uniformity and optimizing reimbursement.

9. Identify any departments where revenue enhancement opportunities may exist.

10. Perform pricing evaluation:

• Identify all items with required modifiers that are missing.
• Identify all zero priced items.
• Identify items that have prices less than established fee schedules.
• Identify all like items, by description and/or CPT/HCPCS with different prices.
• Review markup method applied to item cost to validate accuracy of item charge.
• Provide assistance in setting prices with impact analysis.

11. 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.

12. 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.

13. Establish a process for reviewing and maintaining the CDM on an ongoing basis.

14. 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.

• Thirty two years

Management Team:

• On site auditing and training provided by Jessy Huebner, CHFP with over nine hundred hospital audits personally performed; research and support staff.

Training:

• Ninety-five percent of the onsite time is dedicated to training while resolving issues found in the CDM.  From the basic methodology of how to use the MedCompliance Services “Healthcare Financial Editor” to in-depth discussions on the legal aspects in reimbursement.

CDM Review Methodology:

• Each departmental session starts with a full introduction of the layout of the MedCompliance Services “Healthcare Financial Editor” which is in the Excel format.  The next step is a review of every line of the departments CDM for accuracy of item description with the CPT/HCPC code book, ie: is revenue and CPT/HCPC code correct, followed by a review of the price to the editors floor and ceiling prices for comparison and correction.    At the end of each session the department director is given a floppy or CD of the editor results for their department.

The MedCompliance Difference:

• The services offered by MedCompliance Services differ from all other services because MedCompliance uses its own copy written editor that merges files and reviews not only the CDM but also Order Entry and all subsystems such as McKesson, Pyxis and Cerner.  Also within the editor is a pricing model for strategic pricing with impact reflected as changes are made.  MedCompliance Services offers ongoing maintenance for problem solving and full CDM audits as often as client desires during the terms of the contract.  We also include unlimited e-mail and telephone support at no additional cost.  

How we keep abreast with government rules and regulations:

• Daily list serve emails are received of updates and web sites are checked for updates by AMA, AHA, CMS, BC/BS and Medicaid.  These updates are merged into the MedCompliance Editor.

• Time required on site for interviews is 2, 3 or 4 days depending on size of facility.
• Each departmental director will be assigned a time, such as this example:

  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 – 3:00            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 – 9:30             OR, Anesthesia & RR
  9:30 – 10:30           Clinics
  10:30 – 11:30         Pulmonary/Respiratory
  11:30 – 12:30         Lunch
  12:30 – 2:00           Cardiac Cath Lab
  2:00 – 3:30             Wrap Up session

2. Average lead time is two weeks to prepare for review and two weeks after on site review is completed to give final recommendation report

3. Critical factor is having all department directors attend their appointed times for interview.

4. Interviews include training on editor, clean up department CDM, and resolve reimbursement issue and to insure CDM is kept clean and in compliance.

5. Resources needed include the following files in this download order:

• CDM - (in Excel format)

  Column A - Dept #

  Column B - Item #

  Column C - Item Description

  Column D - Revenue Code

  Column E – CPT/HCPC Code

Column F – Price


• · Usage - (in Excel format)

  Column A - Item #

  Column B - IP Usage for 2 years

  Column C - OP Usage for 2 years
  

• · Order Entry System - (in Excel format)

  Column A - Item #

Column B – Order Entry Description


• · Sub System - (in Excel format)

  Column A - Item #

  Column B – Sub System Description
  

A set of CD’s must be provided so each department director will receive a copy of their departmental data as seen on the editor.

A room large enough for eight people with a projector and a screen for projection.

1. To maintain the integrity and accuracy of the Healthcare Financial Editor we download updates/changes by Medicaid, Medicare and AMA as they are released.  The editor is a moving target of changing data with a full time staff to maintain that it is kept current.  Programmers are constantly adding new features as requested by our existing clients at no additional expenses to the client.

2. We track performance by continually running the hospitals data through the editor for any changes that need correction to ensure each claim is not getting incorrect information that will cause billing delays and/or rejections.

3. Performance measures are reflected in run reports to enable each client to track their improvement.

4. We have a high customer satisfaction by responding to each and every question and/or request in a timely manner not to exceed 24 hours. 

5. We do not have a written level agreement outside our standard contract because we offer just one level: Complete client satisfaction by delivering the quality of service that our clients expect”

Proper and consistent maintenance of the CDM, while time consuming, is an integral part of the organization’s continued viability.  The on-going code changes made by various payers, along with the impact CDM modifications have on reimbursement, make timely CDM maintenance a priority.  It is strongly recommended establishing proper oversight and control and should also have a mechanism to audit and maintain the CDM.

If you have questions or would like to schedule an on-site visit please contact:

MedCompliance Services, Inc.
Jessy Huebner, CHFP, President
800 West Avenue #1001
Miami Beach, Florida 33139
305-604-7931 Office
305-673-6775 Fax
jessy@medcompliance.com