Hospital Medicare Analysis Reports

Analysis Summary

This report provides summary counts for three summaries, based on the first analysis selected on the Filters pane and summary counts for exceptions found in the analysis process of the CDM file. The summary counts do not include inactive and excluded items. Click the count hyperlink to review the report details.

Export file name:

  • Summary

All CDM Line Items (Prior to Analysis)

This report contains all imported line items that haven’t had an analysis performed on them.

Export file name:

  • All CDM Items

All CDM Line Items (With Analysis)

This report contains all line items imported into VitalCDM with an analysis applied. The counts may be different in this report in comparison to the All CDM Items (Prior to Analysis) report because there may be items that do not meet any analysis report criteria. All individual reports (except Pricing Analysis, SAF Peer Data Analysis, and All Excluded CDM Line Items) displayed on the dropdown for this report are available in one document.

Export file name:

  • All CDM Items

All Excluded CDM Line Items

This report contains all excluded line items that do not appear in any analysis reports. If you need an export, you must run the analysis separately and export the file afterward.

Export file name:

  • All Excluded Items

Usage for All CDM Items

This report totals all usage columns within a CDM file and displays the Total Usage column on the Results table. The Total Usage column can be filtered to show all items with “0” usage or usage less than or over any defined threshold.

APC Payment

This report displays all items that are subject to APC payment.

This report populates the following columns on the Results table:

  • APC
  • APC payment rate
  • APC wage-adjusted payment amount
  • PC variance (the difference between the CDM line item price and the APC payment)

Export file name:

  • APC Payment Exception

Cost to Charge Analysis

This report calculates the variance amount and percent of variance between the cost and charge/price fields.

Deleted CPT®/HCPCS Codes

This report displays all deleted items based on the date entered into the CDM file analysis process.

If a replacement code exists, the REP Exists column indicates that. This column includes a true or false indicator. A true response means the code can be found in the Suggest Codes tab on the Code Detail pane when you select a CPT/HCPCS code from the report.

If Refer to Code(s) is available, the Refer-to Exists column indicates that. This column also includes a true or false indicator. A true response means the code can be found in the Suggest Codes tab on the Code Detail pane when you select a CPT/HCPCS code from the report. Information on whether the codes already exist in the CDM file is also available.

Export file names:

  • No Replacement CPT-HCPCS
  • Replaced CPT-HCPCS
  • Refer-To CPTHCPCS

Device Codes

This report provides a list of all device codes included in the CDM file.

Click the CDM charge code on the Results table to open the Missing Devices tab on the Code Detail pane. This tab provides specific details related to the HCPCS code selected.

Export file names:

  • Devices
  • Missing Devices

Device Relationships

This report provides a listing of all CDM line items that have device to procedure or procedure to device relationships.

Click the CPT/HCPCS code on the Results table to display the Suggested Codes tab on the Code Detail pane. This tab features linked information. There is also a notation in the last column (this column is the same title of the charge code in your CDM file) of any CDM numbers that list the code.

Export file names:

  • Device Relationships
  • Related Codes

Duplicate CPT/HCPCS

This report displays all line items where more than one line item has the same CPT/HCPCS code.

It also features a True/False column if the same CPT/HCPCS code is found in the same department with a different price. The report might be filtered to only reflect true statement results. Revenue codes of 960-989 are taken into consideration when determining a true or false status.

Export file name:

  • Duplicate Code Variance

FAC Fee Schedule Payment

This report displays all items that are subject to LAB or Medicare Physician Fee Schedule (MPFS) payment.

This report displays the following columns on the Results table and Code Detail pane:

  • Fee Type
  • FAC Fee Schedule Payment
  • Fee Schedule Variance (the difference between the CDM line item price and the Fee Schedule payment)
  • APC Status Indicator
  • MPFS Status Code

Export file name:

  • Fee Schedule

Invalid CPT/HCPCS Codes

This report displays all line items with CPT/HCPCS codes that are invalid and unbillable.

Export file name:

  • Invalid CPT-HCPCS

Invalid Modifiers

This report displays all line items with a modifier that is invalid and unbillable.

Export file name:

  • Invalid Modifiers

Invalid Revenue Codes

This report displays all line items with revenue codes that are invalid and unbillable.

Export file name:

  • Invalid Revenue Codes

LCD/NCD

This report displays all CPT/HCPCS codes that are listed in Local Coverage Determination (LCD) or National Coverage Determination (NCD). This report helps determine which codes in the CDM need to meet medical necessity and possibly obtain an Advance Beneficiary Notice (ABN).

Export file name:

  • Codes with Policy

Medicare Code Options

This report lists all the codes in a CDM for which Medicare requires or recommends using a different code instead.

Click the CDM charge code or CPT/HCPCS code on the Results table to open the Suggested Codes tab on the Code Detail pane. This tab shows linked information. There is also a notation in the last column (this column is the same title of the charge code in your CDM file) for any CDM numbers that list the code.

Additionally, you can select the Medicare Crosswalk tab on the Code Detail pane and click the alternate CPT/HCPCS code for more details. You can also select the Add On tab to view CPT/HCPCS codes that may be billed in addition to the primary code, if applicable.

Export file names:

  • Has Medicare Crosswalk
  • Medicare Crosswalk

Missing Primary/Add-On Relationships

This report lists any line items in the CDM file that contain a missing primary code or a missing add-on code within the same department.

Click the CDM charge code or CPT/HCPCS code on the Results table to display the Suggested Codes, Medicare Crosswalk, and Add On tabs on the Code Detail pane. These tabs provide more details and allow you to view missing primary or add-on codes within the same department.

The Missing Related Detail tab downloads as an additional document when this report is exported.

Export file names:

  • Missing Related
  • Missing Related Detail

Not Billable to Medicare Payer (SI M)

This report displays all line items designated to have a status indicator of “M “in the Outpatient Prospective Payment System (OPPS). These line items are not billable to the Medicare Payer or paid under OPPS.

Export file name:

  • Not Billable to Medicare

Not Recognized by Medicare (SI E)

This report displays all items designated to have a status indicator of “E” in the OPPS. These items, codes, and services are not paid and not considered to be non-covered by any Medicare outpatient benefit category.

They are also statutorily excluded by Medicare and are considered not reasonable and necessary. Furthermore, these items are not paid for under OPPS or any other Medicare payment system.

Export file name:

  • Not Recognized by Medicare

Not Recognized by OPPS (SI B)

This report displays all line items designated to have a status indicator of “B” in the OPPS. These codes are not recognized by or paid for under OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). These codes may be paid for by intermediaries when submitted on a different bill type.

For example, bill type 75x (CORF) would not be paid under OPPS. An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x), may be available.

Click the CDM charge code or CPT/HCPCS code on the Results table to display the Suggested Codes tab on the Code Detail pane. This tab shows linked information, along with a notation in the last column of any CDM numbers that list the code. Furthermore, the Medicare Crosswalk tab also displays a list of alternate codes, if available.

The OPPS Medicare Alternate downloads as an additional document when this report is exported.

Export file names:

  • Not Recognized by OPPS
  • OPPS Medicare Alternate

Pricing Analysis

This report shows pricing information obtained from the Standard Analytical File (SAF) published by CMS.

Select Analysis details under the Tools menu. The following are the additional options you can select to add to the Peer Avg Charge and Wage-Adjusted APC in the analysis process:

  • Up to 10 states
  • Hospital bed size (four options)
  • National Percentiles (five options)
  • Teaching/Non-Teaching
  • Urban/Rural as additional

You can select specific options or all available options. Furthermore, this report displays the average charge by CPT/HCPCS codes in the report (if there are more than 10 occurrences in the data file provided by CMS) for each data element selected.

Run the Pricing Analysis report separately before you export the report, if you need an export. This report is not included in the All CDM Line Items analysis export document.

Export file name:

  • Pricing Analysis

PRO Fee Schedule Payment

This report displays all items that are subject to the Medicare Physician Fee Schedule (MPFS) payment.

This report populates the following columns on the Results table:

  • Fee Type
  • PRO Fac Price (Professional Facility Schedule Payment)
  • Fee Schedule Variance (the difference between the CDM line item price and the Fee Schedule payment)
  • APC Status Indicator
  • MPFS Status

Export file name:

  • Profee Schedule

Questionable Revenue Code

This report includes all line items that have an assigned revenue code that does not match Vitalware’s best practice suggestion.

Click the CPT/HCPCS code on the Results table to display the Rev Code tab on the Code Detail pane. This tab features suggested replacements.

Export file name:

  • Questionable Revenue Codes

Reimbursable Drugs

This report provides a listing of all reimbursable drug codes included in the CDM file.

Click a CDM charge code or CPT/HCPCS code on the Results table to display the Missing Reimbursable Drugs tab on the Code Detail pane. This tab shows all reimbursable drug codes that are available but not included in the CDM file.

The Missing Reimbursable Drugs tab downloads as an additional document when this report is exported.

Export file name:

  • Reimbursable Drugs and Missing Reimbursable Drugs

Reimbursable Items/Services

This report includes a listing of all reimbursable and non-surgical CPT/HCPCS codes included in the CDM file.

Click a CDM charge code or CPT/HCPCS code on the Results table to display the Missing Reimbursable Items/Services tab on the Code Detail pane. This tab features all reimbursable and non-surgical CPT/HCPCS code items/services that are available but not included in the CDM file.

These items/services should be considered for future addition to the CDM.

The Missing Reimbursable Items tab downloads as an additional document when this report is exported.

Export file names:

  • Reimbursable Items
  • Missing Reimbursable Items

Revised Description

This report includes all line items in the CDM that had a change to the long description from the previous quarter based on the date of the file analysis.

Click the CPT/HCPCS code on the Results table to display the Revision History tab on the Code Detail pane. This tab features long, medium, and short description details for each Start and End period.

Export file name:

  • Revised Description

SAF Peer Data Analysis

This report displays pricing information obtained from the SAF data file published by CMS.

Select Analysis Details from the Tools menu. You can select up to 20 hospitals to be included in the analysis process.

The SAF threshold for inclusion in the data is 5 billed instances, any CPT/HCPCS code less than that is not included.

This report also includes:

  • The total average price per CPT/HCPCS
  • A calculated variance amount
  • The percent of variance between the price in the CDM file
  • The total combined weighted average price of all hospitals selected.

Professional revenue codes of 960-989 are excluded from this report due to SAF data being specific to facility charges.

If an export is needed, run the SAF Peer Data Analysis separately before you export the report. This report is not included in the All CDM Line Items analysis export document.

Export file name:

  • SAF Peer Data Analysis

Status Indicator and/or Payment Change

This report lists all CDM line items where the CPT/HCPCS code status indicator either changed the payment amount or the status indicator changed (for example, “K” to “N”) when comparing the current quarter to the previous quarter.

Export file name:

  • Status Indicator Payment Change