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November 13, 2006
I suppose I should be embarrassed to admit my ignorance of the world “outside my specialty,” but it’s been evident on so many occasions that there’s no point in trying to play it down anymore. As my years of coding progressed, one day I found myself assigned the task of validating Current Procedural Terminology (CPT) codes being submitted for addition to our facility’s chargemaster. Until this point in my career, I had been proud to know: a) there was such a thing as a chargemaster, b) the name of the person who tended it, and c) how to spell “CPT.” This was nearly a Herculean accomplishment once you take into account my name-dyslexia and the fact that the last time I’d assigned a CPT code was 12 years prior in coder training. The task involved people who wanted to have codes and their respective charges added to the charge description master (CDM). One of the administrative powers decided that the hospital side should make sure the code was valid for us and not just for the physicians’ billing side. Because I wasn’t physically present to object, I was nominated for the job. At our facility, the physicians and hospital are part of the university, so their financial interests are more aligned than might be found in hospitals elsewhere in the medical universe. As a result of this arrangement, the coders on the physicians’ side also handle the charge documents for the hospital side, and, with few exceptions, the hospital coders process only the day surgery, observation, and inpatient cases. And they never even see a charge document, much less know what to do with one. Imagine my surprise then at learning that, in my absence from CPT coding, ambulatory payment classifications had made their appearance on the medical scene. People now cared about modifiers and pass-through codes, Healthcare Common Procedure Coding System (HCPCS) codes, new technology codes, and—gasp—evaluation and management codes. Suddenly, I was getting spreadsheets via e-mail from all clinical areas, including pharmacy and cardiology, with dozens of requests to validate their respective code uses. My inbox took regular mail with hard-copy requests from departments all over the city, while my head spun like the girl’s in The Exorcist, and my title was informally changed from senior manager to bottleneck in the CDM process. I questioned everything before I’d sign anything—which turned out to be good for my learning curve but bad for my overall popularity with the other concerned parties. And that, my friends, is where the charge fairies became known to me. I had understood on a subliminal level that somehow, somewhere, charges were put on the claims that went out from the billing departments. The details were unknown to me and—until the death threats started hitting my inbox attached to the CDM requests—this process hadn’t been too important to me. We evolved to survive—well, at least so I’d be more likely to survive the responsibility—and we wrangled with the needs of all concerned parties and their respective schedules. Eventually, we formed a group that meets weekly to review, evaluate on multiple levels, and approve the requests for additions and modifications to the facility chargemaster. The horror was that the only time everyone had free on their calendars was Wednesday at 8 am. The rescue was that this is marginally better than Friday at 4 pm, so we decided to count our blessings and lock in the meeting time. You can probably visualize the faces at that time of the morning for a group that included physician’s and hospital billing, physician’s and hospital coding, the chargemaster herself, university billing compliance, and any department that had personal concerns that week. Reality tagged us with the informal moniker of “The Wednesday Morning Coffee Club” due to the need for stimulant to focus everyone’s eyes simultaneously at such an early hour. As the scope of the gathered knowledge, influence, and dedication to improvement became more evident, we added the official and infinitely more informative title of CDM Integrity Committee. To my amazement, I discovered that not only did the code in question need to be verified for technical correctness, there were also all sorts of issues attached to the code. The code and the description must be correct for the procedure being performed. For example, charges are calculated based on the procedure’s usual cost and a market adjustment has to be made based on a cost-to-charge ratio that I don’t understand. Billing areas for all payors have to evaluate each requisition to make sure the appropriate revenue codes are reported, HCPCS codes are correct where indicated, and invalid codes are deactivated and new codes are added. Appropriateness of venue, if you will, may come into play. Is a Medicare inpatient-only procedure being requested as an addition to a revenue department for an outpatient clinic? And if so, why? Did a department request additions for a new vaccine but forget to include a code for delivery? Is the area that intends to do the billing actually performing the service and/or purchasing the supply? Did everyone blow off adding a code that Medicare and Medicaid don’t cover and forget that a huge population of commercial carriers is happy to cover the service? Compliance reviews the overall requisition to determine
that the requestor is billing appropriately according to state and federal
guidelines for all payors. The chargemaster coordinator makes sure the
software that interfaces charges from its users is operating correctly
and that manually posted charges have the correct forms from each area.
It’s been an incredibly enlightening experience for someone whose response to related questions used to be, “I don’t know, we just code. The charge fairies take care of the charges.” Today, the response is, “I don’t know; we’ll review it at the CDM meeting next Wednesday and find out.” Then, it will get figured out and implemented correctly. We won’t wait for an outside vendor to see whether we’ve been doing something wrong for three years and we won’t wait until the chargemaster system blows up from the electronic clutter of ages. We can’t claim perfection by any means, but we’re light-years ahead of where we were when the coder first met the charge fairies so many years ago. — Judy Sturgeon, CCS, is the hospital coding
senior manager at The University of Texas Medical Branch in Galveston.
While her initial education was in medical technology, she has been
in hospital coding and appeal management for the past 18 years.
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