Chargemasters: ED and Provider-Based Clinics

Description:

• For coding and billing, what is different about the ED and provider-based clinics?
• How can we establish the ED portion of the chargemaster to capture all charges?
• Do we need to have line items in the chargemaster for non-emergency care in the ED?
• Does our fast-track need special attention in the chargemaster?
• Why are our ED charges so high?
• Should the ED modifiers be in the chargemaster?
• What is this provider-based clinic split fee schedule?
• How can we establish our chargemaster to accommodate provider-based clinic activities and freestanding clinics at the same time?
• Do we need to put the non-physician practitioner fees in the chargemaster?

Objectives of the session: 

1. To review the Provider-Based Rule (PBR).
2. To understand the differences between freestanding and provider-based clinics.
3. To understand the economic advantages of provider-based clinics.
4. To appreciate special compliance concerns associated with provider-based status.
5. To appreciate provider-based clinical services within the hospital.
6. To understand ED services and the impact on the chargemaster.
7. To delineate how the chargemaster should be established to support coding and billing for both technical and professional components in the ED and provider-based clinics.
8. To discuss operation issues such as setting fees, patient relations and medical staff organizational structuring.
9. To delineate the various types of clinics and operations that can be provider-based.
10. To appreciate organizing multiple provider-based clinics.
11. To review Section 603 of BiBA 2015 and the 21st Century Cures Act.
12. To work through several case studies involving the establishment of the chargemaster for the ED and provider-based clinics.

Agenda for the session: 

1. Review of the Provider-Based Rule (PBR)
   1. Development of the PBR
   2. 42 CFR §413.65
   3. Review of Definitions
   4. Rules and Regulations
   5. Recognition by Non-Medicare Third-Party Payers
   6. Current Legislative Activity
2. Economic Advantages of Provider-Based Status
   1. Clinics
   2. Clinical Services
   3. Costs for Provider-Based Status
   4. Recognizing Provider-Based Clinical Services
3. Review of the ED As Provider-Based
   1. Types and Levels of Services
   2. Professional vs. Facility Coding and Billing
   3. Establishing Fee Structures
   4. Non-Emergent Care in the ED
4. Establishing the Chargemaster
   1. Technical Component – UB-04
   2. Professional Component - 1500
   3. Setting Fee Schedules
   4. E/M Levels
   5. Coding and Modifiers
5. Special Concerns
   1. Maintaining Patient Relations
   2. Medical Staff Organization
   3. Meeting Other Provider-Based Rule Requirements
6. Special Types of Provider-Based Clinics
   1. Wound Care Clinics
   2. Specialty Clinics
   3. Pain Management Clinics
   4. Medication Management Clinics
7. Recent Developments
   1. CMS Data Gathering
   2. BiBA 2015 Payment for Off-Campus Clinics
   3. 21st Century Act and Impact on Provider-Based Clinics

Who should attend:  Chargemaster personnel, compliance personnel, claims transaction personnel, coding personnel, ED management staff, provider-based clinic management staff, and all personnel involved with provider-based clinics and/or clinical operations including nursing staff and interested physicians.