Everything is Blooming – Is Your Cath Lab Revenue?

Now that winter is over and spring is upon us, it will not be long until the daffodils bloom. Seeing the world around us come back to life gives us a feeling of wanting to dust off the cobwebs, open the windows, and let the fresh air rejuvenate our spirit – spring cleaning time! This is also the perfect time to focus on new beginnings in the cath lab…starting with revenue.

With profit margins narrowing, there has been increasing scrutiny of proper reimbursement, most particularly in the cath lab, since more and more procedures are shifting to the outpatient setting. Corazon believes one critical strategy to ensure optimal payment is an accurate and complete Charge Description Master (CDM), also known colloquially as the ‘chargemaster’. Without regularly updating the CDM, hospitals risk not collecting proper reimbursement for services rendered, which can create millions of lost dollars annually.  

Create a chargemaster committee

First and foremost, we recommend creating a chargemaster committee that is responsible for updating the cath lab chargemaster. There may be an organization-wide chargemaster committee that already exists; however, a designated cath lab committee is optimal. In the past, one individual, usually from the financial/business department, was responsible for making annual changes. The complexity and importance of a properly configured CDM has in recent years required more hands to be involved, due to the high volume of cases and the intricacy of procedures. In Corazon’s experience, a combination of clinical and financial positions bring both procedural factors as well as compliance input into ensuring an accurate document. Committee positions and their associated responsibilities are outlined in Table 1.

At a minimum, the committee should meet quarterly to determine if CDM revisions are necessary due to CMS coding and/or billing changes, implementation of new procedures or services, and changes in medical technology.

Address coding changes

After the committee is organized and active, the team should focus on any coding changes that directly affect the cath lab chargemaster. Since CPT code changes are addressed in the CMS Hospital Outpatient Prospective Payment System (HOPPS), the committee should pay particular attention to the Federal Register publication every November, which outlines any changes that take effect the following January. Particularly relevant to this year, CMS made significant coding changes to procedures performed in the cath lab, such as ablations, transcatheter aortic valve replacement/implantation (TAVR/TAVI), and percutaneous coronary intervention (PCI), that took effect January 1, 2013. Chargemaster updates to reflect these changes should have been made and ready to implement prior to the first of this year. Specific updates are outlined in Tables 2-4. 

Ablation coding changes

Five new codes were created to bundle ablations and electrophysiology (EPS) studies, since they were generally performed together, as well as better describe the technology and innovation of current procedures (Table 2).

Transcatheter aortic valve replacement/implantation (TAVR/TAVI) coding changes

Eight new Category I codes and one Category III code were created to signify that TAVR/TAVI procedures are widely accepted and consistent among physicians.  

As specified in section 20.32 of the National Coverage Determination (NCD) Manual, TAVR/TAVI requires the interventional cardiologist and a cardiothoracic surgeon to jointly participate in the intraoperative technical aspects of TAVR. Modifier -62 (two surgeons) must be applied to all TAVR/TAVI procedure codes with exception of codes 33367, 33368, and 33369. Obviously, this can have profound practice implications for facilities that have already been offering this advanced procedure. Corazon suggests that organizations do a retrospective review of TAVR claims to check if modifier -62 has been billed, and take corrective action for the future if necessary.

For indications that are not approved by the FDA, patients must be enrolled in qualifying clinical studies, which requires a Q0 Modifier (investigational clinical service provided in a clinical research study that is in an approved clinical research study).

PCI coding changes

Thirteen new PCI codes were created to better reflect the procedure complexity. CMS re-bundled the work associated with the placement of a stent in a specific arterial branch into the base code for the “placement of a stent in an artery” instead of paying for the additional branches. CMS also added the ramus intermedius (RI) and left main (LM) under the definition of “major” vessel, which extends the list of modifiers. Corazon recommends hospitals append the modifiers to the appropriate procedure codes and add them into the chargemaster. Adding the combination of codes and modifiers will be time consuming at the outset and extend the chargemaster list; however, this initiative could save valuable time, effort, and dollars in the long term.

Establish a charge amount

Since hospital charges and the rationale to create the charge amount have received recent negative national press, it is essential that organizations understand the process for establishing an appropriate and defendable charge for the new codes listed above. To receive the full Medicare payment amount, the department manager must set charges to be at a minimum value of the Medicare payment amount. This scenario for establishing minimum charges also holds true for other payor contracts as well.  

For example, if the insurance company contracts to pay $4,000 per outpatient for PCI procedures, but the patient bill is $3,800, the insurance company will pay the $3,800. Hospital prices are determined in various ways, but the chargemaster committee’s goal is to assure that reimbursement reflects a match with the overall resources that were consumed, which assures the hospital receives proper payment for the care that was delivered. Addendum B of the Final 2013 HOPPS details the outpatient payment amount by CPT code and the associated APC code.  To reveal potential revenue opportunities, compare Addendum B to the chargemaster. Medicare will reimburse the lower amount of the payment listed in Addendum B or the hospital’s billed amount.

Conclusion

There are certainly many other maintenance tasks that are required by the chargemaster committee; however, the overarching goal of that team should focus on proper reimbursement. Performing regularly scheduled quarterly chargemaster updates will help your hospital avoid potentially costly errors that result from outdated or incorrect information. So take the time to achieve the necessary ‘spring cleaning’ of your chargemaster to ensure financial profitability, now and in the future!  

Kristin is a decision support specialist and Cheyne is a healthcare sales representative at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedics specialties, and consulting, recruitment, interim management, and physician practice & alignment services to clients across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Kristin, email ktruesdell@corazoninc.com, and to reach Cheyne, email cheyne.vernon@corazoninc.com.    

Reference

1. The basics of Medicare enrollment for physicians who infrequently receive Medicare reimbursement. MLN Matters Fact Sheet. ICN 006881. Department of Health & Human Services/Center for Medicare and Medicaid Services. January 15, 2013.