APC
Implemented in 2000, the Ambulatory Payment Classification, or APC, is the current method by which Medicare and Medicaid reimburse for hospital-based outpatient services under the Outpatient Prospective Payment System (OPPS). Under this program, the facility is paid a fixed payment rate for each procedure regardless of the time or costs actually consumed. Unlike DRG coding for inpatient services, hospitals do not assign APCs to patient services and include them on bills. Instead, the hospital is required to include ICD-9 codes, CPT-4 codes, HCPCS codes, modifiers, and other local codes on the claim to drive the calculation of an APC by the fiscal intermediary.

Charge Capture Audit
Due to the complexity of regulatory rules, hospitals know intuitively that there are services being performed but not billed. The reasons that this occurs are far-reaching and may include such things as not having the item on the charge master, incorrect links between order entry and the charge system, incomplete documentation, inaccurate coding, or other billing procedure “leaks”. MedAssets Net Revenue Systems’ charge capture audit provides a systematic process for identifying revenue integrity and other process management issues that can result in lost charge opportunities.

Charge Description Master
see Charge Master

Charge Master
Sometimes called the Charge Description Master (CDM) or Service Item Master, the Charge Master is a file contained within the hospital’s financial system that links tens of thousands of patient care activities to items that appear on a patient’s bill. The charge master also contains codes (CPT-4, HCPCS, UB-92) used for reimbursement. Hospitals have a great deal of flexibility in how charge items are defined, structured, described, and maintained in the charge master. As a result, it is challenging for hospitals to comply with federal reimbursement rules while also ensuring that complete, legitimate patient charges are captured for billing.

Comparative Rate Modeling
Unique to MedAssets Net Revenue Sytems, this advanced pricing model provides a proven means of recouping the revenues that often are lost during charge master review projects, while also realigning the hospital’s price structure within its market. Comparative Rate Modeling incorporates the most complex managed care provisions and uses MedAssets’ Comparative Pricing Database, the most comprehensive, accurate, and detailed pricing database available.

Compliant Coding
Assignment of CPT-4 and HCPCS codes to patient bills in accordance with the guidelines of the Office of the Inspector General (OIG) and in a manner that results in appropriate reimbursement for services rendered.

Lost Charges
see Charge Capture Audit

Revenue cycle master
A logically linked set of master files spanning the patient care and patient accounting systems that define and control ordering, processing, administering, and billing patient care activities. The structure and description of detailed items in these files determine the hospital’s ability to deliver care appropriately, maintain compliance with Federal regulations, and get reimbursed for patient services. The revenue cycle master includes files contained within the patient care, order entry, pharmacy, laboratory, radiology, surgery, resource management, and patient accounting systems.