Conference Description:

Revenue Integrity and Chargemaster Boot Camp


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Course Overview

The Revenue Integrity and Chargemaster Boot Camp provides education on chargemaster and revenue integrity concepts in a classroom format. The program will relate the chargemaster function to revenue cycle and revenue integrity functions, including cost reporting and key operational issues, such as coverage, clinical documentation, charge capture, and coding.

It will also provide context for chargemaster set-up and maintenance within revenue integrity with an objective to help avoid pre- and post- billing edits and payer denials.


You will leave this program knowing how to:

Provide formal, organized education and training for revenue integrity and chargemaster staff
Provide context for the intersection of the chargemaster with clinical/revenue departments, charge capture, coding, finance, and patient access and billing
Walk attendees through CMS regulatory requirements for pricing and charging patients, as well as key relationships between the chargemaster and provider cost reporting
Give detailed instructions for the majority of revenue codes for optimal chargemaster setup, maintenance, charge capture, and documentation issues
Review chargemaster issues for commercial/managed care versus CMS requirements

Revenue Integrity and Chargemaster Boot Camp
Learning Objectives

At the conclusion of this educational activity, participants will be able to:

Equip hospital, payer and other healthcare specialists with effective and efficient strategies to obtain and maintain overall revenue integrity for both governmental and non-governmental payers
Gain a working understanding of revenue integrity principles associated with eligibility, coverage, coding, billing and payment using fee-for-service Medicare requirements as a framework
Explain standard charge description master (CDM) elements, design and relationship to the general ledger and revenue cycle processes of coding and billing
Review claim requirements and specific issues of CDM set-up and maintenance by revenue code with associated cost reporting principles
Exemplify outpatient and inpatient hospital prospective payment systems reimbursement and rate setting methodologies as well as appeal strategies to protect revenue


Revenue Integrity and Chargemaster Boot Camp
Outline/Agenda

Module 1: Revenue Integrity Overview and Resources
Revenue integrity functions and key principles including how the chargemaster fits into over revenue integrity functions
Medicare and other revenue integrity and chargemaster resources
Understanding authoritative sources such as statutes, regulations, manuals, transmittals and other Medicare rules and guidelines
Module 2: Eligibility Principles
Review major and different types of medical insurances
Principles of health insurance eligibility and verification of insurance
Coordination of Benefits & Subrogation
Medicare Secondary Payer (MSP) concepts
Module 3: Benefits, Coverage and Medical Necessity
Review how insurance benefits are structured for hospital and other services
The importance of coverage, medical necessity and both implied and specifically excluded benefits
Medicare’s prohibition against unbundling for inpatient and outpatient hospital services
Pre-service coverage analysis and associated waiver/notice requirements
Serious preventable events and relationship to risk management
Investigational/experimental services and implications for coverage
Module 4: Provider Types, Licensure, Enrollment, & Privileges
Types of facilities, providers, physicians, practitioners and suppliers
Provider-based department requirements including implications of Section 603 of the Bipartisan Budget Act of 2015
Licensure, scope of practice, privileging and relationship to coverage
Conditions of participation, survey & certification and accreditation
Importance of medical staff bylaws & regulations and relationship to conditions of payment
Exercises: Concepts of Revenue Integrity
Module 5: Charge Description Master Structure and Charge Capture Principles
Definition, purpose and key fields of a chargemaster
Concepts for code set up in CDMs and relationship to HIM coding
Principles of bundled services per CPT definition vs reporting packaged services and implications for separate charging of packaged services
Strategies to address payer differences in the chargemaster
The relationship of chargemaster to overall AR System
Concepts for pricing services and why APCs are not a good gauge for pricing hospital services
Chargemaster, general ledger and relationship to cost reporting
Module 6: Claims Submission Fundamentals and Code Edits
Key UB-04 fields applicable to hospital services
HIPAA transaction sets including ICD-10 and HCPCS codes
Common claim edits including NCCI and MUEs
Other transaction sets applicable to the revenue cycle such as eligibility, payment, claim status and denial transaction sets
Module 7: Special Medicare Billing Issues
Billing requirements for outpatient repetitive versus non-repetitive recurring and non-recurring services
The three-day payment window and outpatient services billed on inpatient claims
Billing of non-covered inpatient and outpatient services
Patient status and billing inpatient non-medically necessary services
Exercises: CDM Structure, Claims and Billing Issues
Module 8: Strategies and Key Issues by Revenue Code: Routine Services and Observation
Key concepts for accommodation codes and routine services, including outpatients in beds, specialty care units and observation services
Coding and edit issues for revenue codes associated with routine services and observation
Major factors of coverage for these services
Applicable inpatient and outpatient payment concepts
General ledger and finance considerations including pricing and charge capture
Module 9: Strategies and Key Issues by Revenue Code: Ancillary Services
Key concepts for major ancillary service departments, including peri-operative services, emergency, cardiology, diagnostic imaging, pharmacy and supplies
Coding and edit issues for revenue codes associated with ancillary services
Major factors of coverage for these services
Applicable inpatient and outpatient payment concepts
General ledger and finance considerations including pricing and charge capture
Module 10: Strategies and Key Issues by Revenue Code: Other Departments
Key concepts for other common ancillary service departments, including respiratory therapy, clinics, behavioral health, and preventive services
Coding and edit issues for revenue codes associated with other departments
Major factors of coverage for these services
Applicable inpatient and outpatient payment concepts
General ledger and finance considerations including pricing and charge capture
Exercises: Routine and Ancillary Services by Revenue Code
Module 11: Introduction to Payment Systems
Review inpatient payment systems including DRGs, APR-DRGs, Case Rates and Per Diems
Discuss hospital outpatient hospital payment systems including OPPS & APCs, eAPGs, fee schedules and percent of charges
Review outpatient surgery payment methodologies such as ASC and ambulatory fee schedules
Review other ambulatory service payment systems such as the physician fee schedule (MPFS), DMEPOS, Clinical Lab Fee Schedule
Review emerging payment methodologies such as Bundled/Episode Payments (CJR) and Value-Based Purchasing
Module 12: Outpatient Prospective Payment System (OPPS)
Understanding OPPS payable services and structure of APCs
Learn how to determine whether services are paid separately or packaged
Understand C-APCs and complexity adjustments
Understand impact of inpatient deductible cap on co-payments for beneficiaries
Module 13: Medicare Physician Fee Schedule (MPFS)
The resource-based relative value system
Relative value unit (RVU) structure
Site of service adjustments for facility and non-facility services
Global versus technical and professional components
Payment policy indicators
Exercises: Payment Systems
Module 14: Charge Description Master Management and Maintenance Strategies
Issues surrounding the annual chargemaster updates including pricing, HCPCS codes, charge items with no volume
Strategies to work collaboratively with departments
Importance of patient account and charge reconciliation
Tracking CDM changes for compliance
Charge integrity monitoring and reducing unexplained variation in claims
Module 15: Denial Management
Principles of denial management
Adjustment claims and automated provider reopening
Initial and revised determinations and appeal rights
Levels of appeal and timelines for filing
Types of auditors including external auditors from commercial plans
Module 16: Payer Contracting Strategies
Concept and criteria for carve out options
Importance of tracking administrative cost by payer and developing and trending payer scorecards
Contract negotiations and annual price increase limits/caps applicable to chargemaster
Exercises: Strategies for CDM Management, Denials and Payer Contracting

Course Outline/Agenda subject to change.


Please contact the event manager Marilyn ([email protected] ) below for:
- Multiple participant discounts
- Price quotations or visa invitation letters
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