The stakes are high for chargemaster coordinators at a time when hospitals are operating on razor thin margins and federal price transparency requirements have increased scrutiny over healthcare pricing.
They must navigate not only shifting CMS regulations, but also changes to coding and reimbursement rules from private payors. Errors and discrepancies can result in lost revenue or cause patients to receive a surprise bill if an insurer denies payment. Maintenance is a constant process for hospital teams to ensure charges for supplies, medications and healthcare services are properly and accurately billed. Every organization delivering patient care needs a system ind place.
Maintenance means ensuring all coding is correct, complete, and compliant—not just today but every day. If inaccuracies or inconsistencies exist between what is captured in a patient’s record in the EHR and what is being reported on the chargemaster, the result will likely be lost reimbursement.
- A few of the common issues include:
- Bad data
- Deleted, replaced, invalid CPT/HCPCS codes
- Visibility of descriptions in the machine readable file
- Zero-price items
- Ability to defend CPT/ HCPCS codes that exist multiple times with different pricing
Challenges don’t come strictly from private insurers, as Medicare requires very specific coding and claim filing if reimbursement is expected from the Centers for Medicare & Medicaid Services (CMS). The agency updates its prospective payment systems every year, but there are additional updates made quarterly, with other modifications such as transmittals and local coverage determinations (LCD) happening daily. Keeping up requires prompt response to ensure compliance.
Private insurers typically follow in the footsteps of CMS with certain changes to coding and reimbursement, and they also have their own rules and processes.
To put it plainly, there are multiple layers of complexity, and chargemaster coordinators must ensure billing complies with both federal and payer-specific regulations. Hospitals typically use software applications to manage all these moving parts to ensure efficiency and compliance.
Work with care teams
Improper coding isn’t a problem that begins and ends with billing. A complete and accurate chargemaster enables providers to correctly order and bill for their services through the EHR. Further, workflows need to be in place to verify that line-item descriptions match their respective CPT/HCPCS codes. If a code used for billing does not match the care provided, codes must be changed, and staff—including providers—must be notified.
All of the above requires auditing code sets in the chargemaster and checking them for accuracy and completeness, as payors and regulators adjust policy as providers adjust care routines. Hospitals should take time to regularly perform these audits.
Without a complete code set, it’s inevitable that some aspects of patient care aren’t reimbursed fully. Common oversights include drugs administered during a patient’s stay, report readings, and procedure times.
Care coordinators can help ensure providers and support staff understand how to completely code a service by taking time to understand the services provided to patients in each department and reviewing codes with staff to determine if and when new codes are necessary.
Chargemaster and line-item entries must accurately match services rendered or any claim can be flagged, resulting in delayed or denied reimbursement.
Chargemaster maintenance aligns with transparency
Hospitals must review their chargemaster to maintain compliance with not only federal and commercial payor rules, but sometimes state and local standards as well. It isn’t just about revenue and fair reimbursement, as doing so is imperative for meeting price transparency mandates and helps to build trust with patients, providers, and the community.
Hospitals could face penalties if their billing practices lead to complaints and investigations into pricing policies. Adhering to all regulations and ensuring either bundled or unbundled code sets accurately reflect the care provided is good policy from both a business and patient-service standpoint. An accurate and reasonable bill also reflects effective chargemaster maintenance and practices.
To help manage chargemaster processes and systems, expert solutions are available to automate certain functions and flag overlooked errors that could lead to a denied claim.
For more, check out The Craneware Group’s 2025 Best in KLAS® Trisus automated chargemaster solution, which assesses compliance risks and analyzes pricing integrity to help build a solid foundation for optimizing and maintaining revenue integrity. If you’d like to request a demo, please contact [email protected].