Revenue Integrity Q&A: Revenue codes, charge reconciliation, and Medicare HMO patient status rules

Wednesday, June 6, 2018

Revenue integrity professionals are curious and resourceful. They need to be this way given that at many organizations it’s still a new department and title with evolving responsibilities. As NAHRI was getting off the ground, one of the comments we frequently heard from revenue integrity professionals was that they needed a place to network with peers and get answers and advice for tricky revenue integrity problems.

The NAHRI Forums were created to help address that need. NAHRI members can post questions, share tips, and discuss the tough questions revenue integrity professionals routinely encounter. The forum categories cover the wide range of topics that regularly crop up in revenue integrity include Billing and Claims, Chargemaster and Charge Capture, and Coding and Documentation. And at the request of members, NAHRI recently launched setting specific topics: Physician Practice/Freestanding Clinics and Post-Acute Healthcare Settings.

Here are the questions that have sparked the most conversation on the NAHRI Forums.

Q: Do revenue codes have standard meanings for all payers? We are finding that payers are telling us to use different codes than we would normally use for Medicare.
Revenue codes are part of the standard transaction sets adopted by HIPPA. The National Uniform Billing Committee’s (NUBC) Official UB-04 Data Specifications Manual contains the standard definitions for revenue codes. The official electronic version of this manual is available from the American Hospital Association, and every business office should have access even if they have an editorial version of the codes from another source. In addition to the standard definitions manual, the electronic version comes with an extensive archive of NUBC committee minutes that provide helpful background for some codes/code sets.

That said, payers should be using the codes according to their standard definitions, and if you find they are not, you can bring it to their attention. If they do not correct, there is a method of reporting a violation to the OCR—not that it will come to that, but that is a method to enforce compliance. One of the problems I've found is that the definitions are so general that the two codes CMS and the payer are using may both fit and each payer has established their own edits that require the code they are instructing you to use.  However, your system should be able to translate these in the background by payer type once you identify the code required, which I know is the big challenge.

Q: How does your organization handle charge reconciliation? Is it the responsibility of the department or does your revenue integrity department reconcile?
It is the responsibility of the department to reconcile their charges daily. I do have one team member in place that trains and holds the departments responsible to ensure that the departments are monitoring their charges. The departments send reports to the charge reconciliation analyst once completed. Our revenue integrity team is notified and gets involved when charges and/or revenue direction opportunities arise.

Q: How can I learn about Medicare HMO guidelines for patient status?
The Medicare Managed Care Manual states: “Billing and Payment: MA [Medicare Advantage] plans need not follow original Medicare claims processing procedures. MA plans may create their own billing and payment procedures as long as providers—whether contracted or not—are paid accurately, timely and with an audit trail.”
So it does not matter what CMS says as far as billing: the MA plans can do what they want if you let them do it. My philosophy is that if they tell you to go ahead and bill observation, then do it.

Q: When a department or service line wants to deploy a new device how does your team evaluate the financial impact?
First question: Who allowed that device to be ordered for use at the hospital without an analysis being done? You need to look at the following factors:

  1. FDA/CMS/Insurance approvals
  2. Medical necessity, appropriate use guidelines
  3. Equipment costs—fixed and per procedure
  4. Staff training
  5. Reimbursement: Diagnosis Related Group/Ambulatory Payment Classification/Fee schedule
  6. Precertification requirements
  7. Expertise of physicians

The last is most important to me. Does patient number one know the doctor has never done the surgery on a human being ever? What's the learning curve?


Do you have a revenue integrity question that’s stumped your organization? Do you want to brainstorm management and program design concepts with peers? Visit the NAHRI Forums to get your answers.