Optimizing reimbursement is on the forefront of revenue cycle management.  Have you asked yourself or your organization: are we losing revenue because your fee schedule is not up to date?  Are you capturing all the charges you could?  Is your fee schedule correct and current concerning CPTs, revenue codes (Medicare encounter rate), and descriptions?  Do you have any deleted CPTs or terminated services still active in your fee schedule?  Is your mode of charge entry (encounter form or electronic charge capture) updated and maintained?  If the answer to any of these questions is “I don’t know” or “I’m not sure”; then it’s time to consider a Fee Schedule review.

The following is a list of steps you should take in order to complete a Fee Schedule review and begin to understand whether your Fee Schedule is “healthy” or needs a clean-up. Having a complete understanding of the operations of the clinical being reviewed is critical to revenue capture improvement.

1.       Download and Review Your CHC Fee Schedule.

The information downloaded should consist of at least the following:

• CPT/HCPCS code
• Charge Code Description
• Charge Amount
• Effective Date/Create Date
• Revenue Code (Medicare encounter rate)
• Current/YTD Volume (Units) and Revenue
• 2 years Prior Volume (Units) and Revenue

The downloaded Fee Schedule should be validated against a billing and coding compliance tool to check for valid CPT/HCPCS codes and Revenue Codes (if applicable).  Familiarity with the services being performed in a clinical area and the associated CPT/HCPCS is critical for this part of the review.

“Surgical procedures furnished in an RHC or FQHC by an RHC or FQHC practitioner are considered RHC and FQHC services.  For RHC or FQHC services, the RHC or FQHC is paid based on its all-inclusive rate and is not subject to the Medicare global billing requirements.”   Medicare Benefit Manual, Chapter 13.40.4  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf

Other commercial payors would follow their global billing requirements.

For example, in a GYN setting, you may be doing endometrial biopsies, vulvar biopsies and IUD removal/insertion procedures.  These should be documented according to surgical guidelines and billed as a FQHC service where appropriate.

Key Finding- A number of times there are outdated CPTs.  The descriptions in the file should be compared to the current CPT/HCPCS manuals or downloaded descriptions from AMA and CMS. Deleted CPTs are sometimes missed from the Fee Schedule.

Key Finding- Review hard-coded modifiers (i.e., permanently affixed within the practiced management system) vs. manually entered modifiers.  Modifiers used may not be correct or up to date causing error queue issues or denials.

Key Finding-  Reviewing volumes is important for analyzing shifts in services being performed and an opportunity to clean up the fee schedule of unused charge codes.

2.       Obtain copies of all encounter forms used and review against Fee Schedule download file.

Make sure that the copies of the encounter forms are the most recent and are the ones currently being used by staff.

Key Finding-Most often the charge codes in the fee schedule and the charge codes on the encounter form are not in sync.  This is big potential for lost revenue.  If the services are on the encounter form but not in the fee schedule charges are not going anywhere.

Key Finding- There have been a number of charges on the encounter form containing different descriptions than what is in the  fee schedule, hence billing incorrect services on the claim form.

Key Finding- Deleted CPTS still existing on the encounter form.  Often times there are more appropriate CPTs for services being rendered but not being used.

Key Finding- Reviewing volume sometimes reveals services no longer being performed.  The encounter form should be reviewed and updated periodically for services performed.  Placement of services on the encounter form should be done to create operational efficiency.

3.       Review all electronic charge entry screens/printouts against Fee Schedule download file

If charges are entered from an encounter form into a charge entry screen, the encounter form should be designed to flow in a logical, efficient order and be matched against charges in the charge entry screen. Strategically designing the form and screens will help with efficiency and accuracy of charges entered.

Key Finding- Charge entry screens and encounters forms usually have discrepancies and are not design for optimal workflow.

Key Finding- Like the encounter form, the fee schedule and charge entry screens are not always in sync.  A number of times, charge codes are available in the charge entry screens but are not electronically connected to the billing system.  This situation also arises in physician documentation systems that are interfaced.

Summary- Understanding your operations and the process flow from scheduling through billing is key to optimizing reimbursement.  At times there are inefficiencies, miscommunications and IT disconnects which may not be apparent in day-to-day operations.  It is important for revenue cycle operations to stay connected with the clinical operations putting the necessary processes in place for revenue capture and compliance updates.  An annual review at the Fee Schedule level should be performed around code set changes and a complete review of each clinical area in your center should be performed at least every other year.