CDM management: Did someone say uniform billing editor?

Thursday, June 10, 2021

by Tina Rosier, MS, PT

The National Uniform Billing Committee (NUBC) was formally organized in 1975. The goal of the NUBC was to develop and maintain a national uniform billing instrument for use by the healthcare community. The terms “national” and “uniform” would lead one to believe that billing of medical services to an insurance payer should be a standardized process. However, based on current experiences, and although the UB form itself is standard, uniform is probably the last word I would use to describe the overall billing process.

In the past year, I assumed direct responsibility for the charge description master (CDM) team at our facility. I quickly learned that setting up a charge was not as simple as I once thought. The first step might seem cut and dry (i.e., picking the CPT®/HCPCS code, revenue code, and price that Medicare will accept on a claim). This first step then becomes our default for the CDM charge item that flows to the claim. Don’t be naïve and think that the process stops there. What comes next is not consistent at all and can be very frustrating. In fact, figuring out what revenue code and CPT/HCPCS combination each payer will adjudicate is one of the biggest challenges there is when it comes to getting paid correctly for the services provided.

To attempt to meet this challenge, our network created a subgroup of billing, coding, revenue integrity, denials, and CDM staff that meet every other week. Anyone on the team can submit agenda items, which are typically account denials where a certain payer does not “like” the default revenue code/CPT/charge that was submitted on the claim. As a team, we then discuss the payer and denial reason, review revenue code recommendations from our code look-up software, and decide on alternate (ALT) codes that need to be built. Once the group decides, we then turn over the request to the CDM team to build the ALT codes that are needed by payer. This is a constant battle and for this reason, the CDM is a very fluid document that changes every week.

Additionally, some of our recent challenges have come from our commercial payers’ policy changes. For example, last month we started receiving recoupment requests due to some of our 272/275/278/410/460 revenue code CDM items not having HCPCS reported on the claim. This is not required from a Medicare perspective. However, since many of our commercial payers are now expecting them, we must change our CDM processes to include them, which will take additional time and research as new CDM items are created each week.

In summation, as I am sure everyone knows, the CDM is a very complex tool that is the lifeline for how your facility charges, bills, and is paid. It is not uniform in the true sense of the word and understanding the complexity of your facility, CDM file, and regional payers is essential.

About the author

Rosier is the director of revenue integrity at Community Health Network in Indianapolis, Indiana.