EPreward Serving the Heart of CardiologyEP Newsletter

July/August, 2008

Dear EP Staff & Managers,

Many EP Labs are struggling finan-cially and are unable to build and ex-pand their programs due to inadequatereimbursement. The goal of this articleis to introduce EP staff to the reimburse-ment process, assist new managers inthe development of economically viableprograms, and help experienced manag-ers improve their financial return. AsTechs and Nurses are the only hospitalstaff actually in the procedure, your rolein the reimbursement process is criticalin order for the hospital to be paid ap-propriately.

We have added numerous linksthrough the article including a glossaryof reimbursement terms and a sche-matic of the reimbursement process. Wehave also included examples of differentforms and documents in a manner thatmay be copied and utilized by you. Thisarticle is graciously submitted by SalwaBehiery the Director of ElectrophysiologyServices at California Pacific MedicalCenter and Marin General Hospital. Ifyou have insights or information to add,please submit them through the link atthe end of the article and we will addthem to the version archived on thewebsite.

Respectfully,Steve Miller, RN –President EPreward

How to MaximizeYour EP Service

RevenueWith today’s economic realities, and

with HMO and Medicare’s ever shrinking reimbursement rates, we are all facedwith difficult decisions to make so wecan maintain fiscally viable EP services.The following article will highlight someof the reimbursement challenges EP di-rectors and managers face, and offer afew tips on how to deal with them. Westart with the Charge Description Mas-ter.

This IssueMaximize Your EP Service Revenue –For

Managers as well as Staff.Inventory time? Sell your unused items.Catheter tip solicitations? Be smart.

Problem 1: Low or NoReimbursement From Payors

Perhaps this is the single most impor-tant challenge facing us, and greatly af-fects the balance sheet of any EP pro-gram. This is not an easy topic to com-prehensively cover, but here are somebasic and essential steps necessary toaccomplish positive results:

First of all, understand your ChargeDescription Master, also known as the“Charge Master”. This is a master elec-tronic repository of all possible equip-ment and procedure charges which areused in the EP lab. It is prepared evenbefore an EP program is opened forbusiness. The director/manager of theprogram will put this CDM together withhelp from Decision Support and Finance(other involved parties include EP Staff,Accounting, Billing, Revenue Integrity,Purchasing, etc.). From this CDM, a FeeTicket for each procedure is generatedthat is sent to the payor.

The electrophysiology CDM is the ba-sic structure for deciding what supplieswe will buy, what it will cost to usethem, how much it will cost to do a cer-tain procedure, and finally the totalamount we will charge the patient forour time and efforts. Invest some timeand perhaps some funds for expert help(Coding & Billing resources) to build anaccurate and comprehensive CDM. If

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your hospital is not experienced withelectrophysiology coding and billing youwill need to hire a consultant. Be sure toask for references to evaluate the effec-tiveness of their consultation. (Also,contact your EP catheter manufacturer,who may have support staff that is spe-cifically trained to assist you with reim-bursement matters, and also the HRS ifyou are a member. They are free ofcharge.) This guidance will make an im-mense difference in your reimbursementand budget.

You really can’t get regional specific information from websites or text bookson developing a CDM because it differsfrom state to state. There is a group inour hospital’s finance department called Decision Support (AKA Revenue Integ-rity, and other titles) which will assistswith the process. But before they canhelp you, you need to prepare a com-prehensive list of all your supplies andall your Current Procedural Terminologycodes (list of CPT Codes, look up CPTCodes). Then you sit down and decide:

How long will it take to do a certain pro-cedure? What are the CPT codes in-volved in this procedure? How manystaff members will it take to do the pro-cedure? What supplies are used? To-gether with decision support and financeyou will come up with the CDM. It is avery long process and it is continuouslyrevised. Without this, I can see howmany programs are struggling to stayafloat.

Some questions to ask whilecreating your CDM:

Are all procedures done in the EP labincluded in the CDM? Each lab providesa different set of services and proce-dures, based upon the procedures doneby their Physicians so one CDM does notapply to everybody. We have attachedsample CDM’s to help you see what theylook like at other facilities. Are all ofyour procedures accounted for in thesystem you utilize to report yourcharges? As your physicians expand

Reimbursementsent to Hospital

Charge DescriptionMaster (CDM)

Is an accurate andinclusive accounting ofall procedures done andequipment used in yourEP Lab. Created by EPManager & Finance.Incorporates CPT codes,ICD-9 codes, HCPCScodes, & supplies.

Payors

The payors (Medicare, Insur-ance Company, etc.) reviewsthe coding and chart for eachprocedure for substantiation

You get paid and your departmentgets to purchase new equipment tobetter serve your patients.

Schematic of Optimal Reimbursement Process

Physician progressnotes & Staff

procedure notesneed to support each

procedure andequipment CDMcode submitted.

ChartingInfo from CDMused tocreate ...

Charge SheetIdentification of equip-

ment and procedures onpaper or in electronic

format.

Billing Dept.codes procedures

based on charge sheet,and chart documentation

to create fee ticket.

First: Feeticket sentfor review

Finance Department

Receives payment fromPayors which may or

may not cover all ofactual charges.

Payment ReviewEP Lab, 3rd party or soft-ware review and correct

missing charges anddocumentation

or acceptspayment.

Corrected charges and

documentation resubmitted.

EP Lab, 3rd party,or software reviews& amends fee ticket.

Third: Fee ticketsent to Payors.

Documentsfrom EP Labreviewed &submittedto Billing

Coding

Second:Feeticketreturnedto billing

Start here

Payment sentfor review

Pg. 2

their skills, practice, and equipment, youwill need to update your CDM appropri-ately. Also as you acquire new suppliesand equipment and delete others, yourCDM will need to be revised.

2- Do you know and have principaland associated CPT codes for each pro-cedure? For example; if you are doing aright sided SVT ablation (93651), whichis the principal CPT, there are also otherassociated codes such as 93620(complete EP study with induction) and93609 (mapping a tachycardia site).HRS publishes and sells a very usefulguide to all EP procedures and gives dif-ferent scenarios you can follow that in-clude the associated codes. (This wascited by several managers as their bestreference. Different manufacturers alsohave information on their websites. SeeNews & Resources section of EPreward’s website, look under Coding & Billing.There is also an upcoming webcast onJuly 24th on “CRM and EP Coding Dilem-mas”, andthree educational programs inthe Coding & Billing section of OnlineEducation.)

3- Are your fees and the fee ticketfor each procedure accurate and yourcharges accurately calculated? The cal-culation for the fee ticket is done by pa-tient accounts. The lab will only list thesupplies and the procedures, becauseyou have already given your prices viathe CDM to patient accounts. All of yourstaff should know how to submit acharge sheet for any procedure per-formed in any of the labs (implant, diag-nostic and ablation). The diagnosis ICD-9 (Conduction Disorders, Cardiac Dys-rhythmias, Heart Failure, and Cardio-myopathy) (the procedure ICD-9 codesare covered by the CPT and HCPCScodes and are not needed) need to be

included in the procedure report so youavoid having people who are not familiarwith EP procedures determine thosethings for you. Not all coders are famil-iar with EP and you want to make surethat all of your information is accurate.

You will need to meet with your pa-tient account/finance department andcultivate a good working relationshipwith them. You also need to be aware ofwhat happens to your charges after theyleave the procedure room, as you arethe one who is ultimately responsible forthe financial success of your departmentand lost revenue may occur at any stepalong the way to final reimbursement.For at least a few months ask the billingdepartment to return the fee ticket forreview. Every lab should have one stafftrained be an expert in reviewing thesereports. (A review optimally occurs afterthe charge sheet is filled out, after cod-ing, and after reimbursement. This istime intensive though, and can be modi-fied according to the number of errorsdiscovered at each step. There is soft-ware available that automatically re-views Fee Tickets for completeness ifhaving staff do this is an issue. See Cod-ing & Billing under Manufacturers. Yourfacility may already have review soft-ware in place that just needs to be ex-tended to EP).

The goal is to evaluate these chargesfor accuracy and completeness beforethey are sent out to the payors. Afterpayment, if a procedure was denied orunderpaid inquire about the reasons forthe denial or the payment and amendwhat was missing. You need to knowwhat is allowed for each procedurewhether it is Medicare or private payor.Often times we get underpaid becauseof miscoding, an error in modifiers, lackof understanding on the part of thepayor, etc. Ask what was the reason forthe low payment or no payment andwrite a rebuttal and resubmit the

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write a rebuttal and resubmit the chargesif any of those reasons exist. It will goback to billing after being corrected by thecoder (sometimes the coder did fine butthe charges entered by the EP Lab wereincorrect, or the pt was listed as inpa-tient rather than an outpatient).

4- For each item on your supply list, doyou know its cost and how much youcharge for it? Your purchasing personneland your finance department should be ofgreat help in this matter. Does your CDMreflect this cost/charge ratio in a sensiblemanner? The Accounting department has ahospital-wide accounting system, but webuilt our own EP charge ticket into ourhemodynamic system. As you see in ourprocedural report sample, we also builtthat in Witt, which is now owned by Phil-lips. (This can be done with other EP re-cording systems and the pull down menu’s are a good way to insure all appropriateequipment and procedures are included.Manual procedure #3 charge sheets canalso be used.)

Once your CDM is in place, or if youalready have a good one, your next con-cern should be:

Problem 2: Incompleteprocedure documentationin the operative report:

The operative/procedure report iswhat the coders and then the payorsevaluate for appropriate coding andconsequently payments. A great deal ofcooperation with your EP physician(s) isneeded to come up with a good tem-plate for documentation.

In our labs, we created a templatefor each type of procedure performed.Each of these templates, besides thetechnical procedural report, containskey information both the coders andpayors are interested in verifying. Thishelps the department to be success-fully reimbursed for everything it does.This documentation should contain thefollowing:

1- Pre-procedure diagnosis and itsICD-9 code.

2- Post-procedure diagnosis with itsICD-9 code (even if they are the same).

3- Indication for the procedure.

This part highlights the need for theprocedure in terms of symptoms, du-ration of symptoms and the process ofclinical judgment. This could havebeen explained in the physician’s origi-nal consult note, but coders have littletime to go and look for it somewhereelse in the chart. So, if you want to bepaid appropriately put it in the proce-dure notes where it will be easilyfound.

4- Patient admission status: outpa-tient vs. inpatient vs. observation.Most EP procedures can be performedon an outpatient basis. Medicare andother payors now look for clear docu-mentation as to why the patient needsto be admitted as an inpatient. In ourpost procedure order sets, we ask thephysician to circle one of these optionsand if inpatient is selected, an indica-tion should be stated. Discuss this is-sue with your case management, utili-zation review and finance depart-ments. Be aware of your hospital’s contracting terms with each payor.Each hospital has separate contractswith each of the different payors, e.g.some payors will determine that cer-tain procedures should be done as out-patient. If the patient stays in the hos-pital beyond the outpatient terms,then they will pay the hospital a flatper diem rate which is greatly reducedfrom the outpatient rate. Knowing

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these terms will help you either rene-gotiate pay schedules with the payoror abide by their rules to receive themaximum payment.

Striving for optimal reimbursementis time and money well invested, and itis sometimes best to create a team ap-proach to tackle this issue. This teamshould consist of:

1- You as director/manager of theprogram

2- One or more EP staff members.

3- A representative from patientaccounts/finance

4- One or more representativesfrom the coding team

5- And if possible, the medical di-rector of the program so he/she canhelp you build a consensus amongother EP physicians utilizing your lababout the documentation process.

Enhancing and improving EP reve-nues is no small task. However, noprogram can afford to not be reim-bursed or not be reimbursed enough tocover the ever rising cost of running afinancially viable EP program.

Thank you for your time,

As you know, this is a very complexand difficult issue to address. We real-ize this article has only scratched thesurface. Please take a moment andsend us other steps you take to in-crease your reimbursement. We willadd those comments to the edited ver-sion of this Newsletter, which will bearchived on the website for more peo-ple to benefit from. Your input frompast issues is appreciated. Thank youvery much.

Steve

Have

A

Great

Summer !

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Introducing a new online EP re-source. The associated editor is theauthor of this reimbursement article.It is a new publication dedicated toAtrial Fibrillation. “There will be a section for allied health and I amencouraging RNs and other EP alliedhealth professionals to contributetheir ideas, articles, and discussionsto the site. It is free with open ac-cess to all”. Go to site.