Even after doing this stuff for 10 years there’s still a ton I don’t understand about medical billing. I’m just now starting to dig into Facets, and I’ve run into something I can’t seem to figure out.
I have two Inpatient claims that are the same network from the same Facility, have the same DRG, same billed unit count, and there’s one Revenue Code that has different Billed (or Charged) amount for that same revenue code. I was told that facilities have “Chargemasters” where they are supposed to bill the same amount for the same procedure, so I’m guessing there’s something I’m missing.
Any recommendations on other items on the claims I can look at to figure out why these two claims would have two different billed amounts?
In case that wasn’t clear, I have two claims that look like this, and I’m trying to figure out what field I’m missing that would validate Claim 2 having a higher billed amount.
My first thought is - what is the revenue code. For example rev code 290 - DME general, could both have the same units and have wildly different charges if it is a different device provided. Something like a room and board rev code would hopefully be the same between the two for the same timeframe.
If it is a general or drug rev code, are there HCPCS codes on the line and are they the same code?
That’s a great idea. I’m looking at Inpatient claims so it would be ICD Procedure code I think, but I will see if I can find that and see what it says. Thank you!
That was my first thought, HCPCS and maybe the HCPCS modifier. Like radiation and imaging have claims where the same HCPCS is billed, once with a ‘TC’ for the Technical Component and ‘26’ for the physician component.
BruteForce, can you tell us a bit more about the service in question?
Sure, what the heck. I was a little worried about people I work with finding this thread, but I don’t think anyone on my team even knows about this site, and I don’t care too much if people I know figure out who I am. If I wasn’t so lazy I would just find another example, but meh.
I just picked this example at random, and of course I’m changing things enough that I’m not giving away any sensitive information.
I am still pretty new to our data, so I haven’t been able to find any fields with “HCPCS” in the name. It feels like I’m missing some sort of field that would tell me why one claim is being billed higher than the other. I’m seeing these exact same two amounts on multiple claims, so neither of them are just one-offs.
I think you solved it with the date! I looked at things by incurred date, and there’s a very clear line - the higher amounts only show up in the first half of the year, and the lower amounts in the second! I guess for this one example the charged amount was reduced instead of increased.