Billing & Reimbursement Essentials for CV Professionals-Hospital & Facility Billing Structures in Cardiovascular Care

Video Transcription

Video Summary

This module, presented by Nicole Knight from MedAxiom, focuses on hospital and facility billing structures in cardiovascular care, emphasizing the importance of accurate billing for program revenue and financial sustainability. It covers Medicare Part A reimbursement methods: inpatient services paid via MS-DRGs under the Inpatient Prospective Payment System (IPPS), and outpatient services reimbursed through Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS). Accurate coding and documentation of major and minor complications (MCCs and CCs) critically affect reimbursement levels and case mix index, influencing hospital revenue significantly.<br /><br />The module highlights challenges such as denial risks, documentation gaps, and charge capture accuracy, particularly related to high-cost cardiovascular devices and procedures. It underscores the necessity of maintaining an accurate charge master (CDM), proper revenue code assignment, and diligent reconciliation of charges to costs via the cost-to-charge ratio (CCR). Operational processes must effectively manage patient status transitions (inpatient, observation, outpatient) and prior authorizations to optimize reimbursement.<br /><br />Best practices include strong clinical documentation improvement initiatives, ongoing audits, and collaboration between facility and professional billing teams to reduce revenue leakage and ensure billing integrity. Monitoring performance metrics like case mix index, denial rates, and service migration trends supports financial and clinical alignment critical to sustainable cardiovascular service lines.

Keywords

cardiovascular billing

Medicare Part A reimbursement

MS-DRGs

Ambulatory Payment Classifications

charge master accuracy

clinical documentation improvement

case mix index