WashU Billing Staff

Washington University billing staff reviewing research charges will need access to Epic, OnCore and the Billing Matrix to review and adjudicate charges in the research work queue.

First time user setup

To obtain an account for the Billing Matrix, read the information on the CCS website, https://clinicalstudies.wustl.edu/billing-matrix/, and complete the linked Request Account form at the end of the page.

If you have not already taken the OnCore online Billing Reviewer training for Washington University in St. Louis, you can register through this link.

Once you have access to OnCore, there are three tabs in three different consoles that you should add to favorites for frequent use. This was described in your training; the following steps are required.

CRA Console (Menu > Subjects > CRA Console) to get specific patient visit information including dates and TBD clarifications
Coverage Analysis Console (Menu > Financials > Coverage Analysis Console) to view the billing grid used for charge segregation source of truth
PC Console (Menu > Protocols > PC Console) to view the Staff list

Steps for Charge Review

After you have clicked on the patient you are reviewing in Epic, take note of the following for the charge you are reviewing:
- CPT Code
- Description of Service
- Date of Service
Click on the Green Research option in the patient banner.

The following will appear reflecting all studies the patient is associated with:
Next, go to the Billing Matrix Profile Page for the study/studies that the patient is associated with in Epic. Look for the OnCore? box highlighted below.
1. If this is marked No or is blank, use the Billing Matrix for charge segregation.
2. If this is marked Yes, then go to OnCore and continue with these instructions.

OnCore Review

In the CRA Console, enter the IRB number in the Select Protocol field for a list of patients who have been consented for this study.
1. Confirm “ALL” is showing in the dropdown box. To set "All" as the default in the CRA Console of OnCore, select the "All" option, and then click the "Save Preferences" hyperlink shown in the screenshot above.
2. Note Headers: Note all Column Headers, i.e.: Arm, Status, Status Date, Last Visit, Last Visit Date
3. You can sort this view by MRN or name by clicking on the header you want to sort by. You can also use Save Preference to make this your view every time you log into the CRA Console.
4. If the study has more than one Arm, you can see here to which Arm the patient has been assigned. Make sure to check this information and make note of the Arm. Rarely, a patient can be on more than one arm. See #4a-vi, below for instructions on how to toggle between arms in the subject’s calendar.
Once you find your patient in the list, you will now click on the patient’s Epic MRN, circled in green in the screenshot below, and will be directed to the demographics page for that patient.
1. If there are multiple pages of subjects, you can use the Filter box to enter the subject’s last name or MRN to single your subject out.
2. Making note of the Subject status could help to direct you to the right section of the billing grid if calendars are long. Examples:
  1. For subjects with a status of Not eligible, you will still need to check for a Screening or Baseline visit.
  2. If a subject has a status of On Follow Up, you may need to scroll to the right on a Subject calendar to see those visits.
On the left vertical menu, scroll down and click on Calendar. Double-check that the Subject Name matches the one you were looking for.
You will now be in the patient specific calendar that will show visit dates, but not billing designations. To help navigate this page, click on the Freeze Panes box on the top left of the calendar, shown in the screenshot below.
1. Look across the top to find the date of service you are reviewing. You can see the Planned Date (projected from the calendar build), the Visit Status, and the Visit Date. The visits will not always be in chronological order (i.e. a surgery can be scheduled at any time during the treatment cycle and it could vary by patient). When you’ve located the visit that matches or is close to the date of the charge you are reviewing, make note of the visit name because that is the visit you will be looking for in the Billing Grid, then click on the blue hyperlink visit name (circled in green in the screenshot above). This will open a page with more details about that visit & you can skip to step “b”. If you are not seeing the visit you are looking for or the date shown is incorrect or missing, review the information below for where that visit could be found.
  1. Sometimes, multiple visits can occur on the same day, while other times, a single visit may take place over several days or weeks. For example, an office visit might happen on one day, and the x-ray on another. You’ll learn how to identify these variations later.
  2. Keep in mind the Subject Status you noted on the subject list. You may need to scroll to the right on the subject calendar to see all visits that have been checked in. For example, and End of Treatment or Follow Up visit may have occurred even if many previous visits were not required or checked in . Note that there may be two gray scroll bars at the right of the screen for larger grids. Make sure you are seeing the whole list.
  3. Coordinators are instructed to update the Patient Visit Calendar within 2 business days of the visit occurring. So you may need to reach out to them to see if the visit just wasn’t recorded in OnCore yet.
  4. If you do not see the Visit Date that you are looking for, check to see if there is visit in the Orphaned Visits tab, next to the Calendar tab at the top of the page. If a Visit is no longer required due to a change in the protocol, but had already occurred for some subjects, a new Calendar Version is created and the visit is “orphaned.” Subject visits that were checked in on the previous calendar version will appear here. Look for a date near to your service date under the Visit Date column and click the hyperlink under the Visit column in that row to view the details of the Visit. Again, note the visit name.
  5. If not in the Orphaned Visit tab, check the Additional Visits tab on the left vertical menu. This is where a coordinator might log an unscheduled study related visit or a visit that had to be repeated for some reason. Unless there is a comment indicating that it is a repeat of visit xyz, the procedures in the Additional visits tab should be billed according to the PRN visit on the Billing Grid. A repeat visit should be billed the same as the original visit in the absence of a PRN visit.
  6. If you still don’t see the Visit Date you are looking for, it could be due to the subject being on multiple arms. Rarely, a patient can be on more than one arm. If a subject is enrolled in multiple arms or cohorts, you may need to toggle between calendars to log visits or update information accurately. If this is the case, you will see an Arm Dropdown (see below screenshot) option above the calendar on the right. Click on the other arm and the calendar will switch to that Arm’s Visits.
  7. If you have not found a date of service on or near your charge date, you will need to verify that the service is not listed as a Procedure in a PRN visit on the billing grid in a later step.
2. In the Subject Visit Update Page, below where it says Procedures (noted in screen shot below) click on Expand All to see a list of services that occurred for that subject on or near that date. This page does not show cpt codes. Look down the list to locate the service you are reviewing. If the service occurred on a different date than the rest of the visit shown at the top of the screen, the coordinator is instructed to indicate this in the box next to the procedure. This is why we say to look for a close match to the Visit date. If you see a Procedure representing your charge where the date matches, this is the Visit you will view in the Billing Grid in a later step. Remember(!) the box marked SOC is NOT the source of truth for charge segregation except in the case of a TBD service so you MUST continue on to the next steps.
3. Click Close at the bottom right of the screen to go back to the full calendar. Note the Visit Name (blue hyperlink) where you found your charge. This will be identical to the visit name on the Billing Grid in the next step.
Open the Coverage Analysis Console, click Billing Grid on the left Vertical menu. Here you will see the Billing Grid Display Filters. This view can vary. It will only show certain fields if there are options for those fields that apply to this protocol. TIP: You can also open two instances of OnCore to keep the Billing Grid on one screen and the Subject calendar on the other. You can do this by right-clicking on the Coverage Analyst Console link in your Favorites Bar & clicking Open link in new window.
1. You may see a Calendar Version field at the top left. A new calendar version is created when there has been a change to the protocol requirements OR when an error or some piece of new information that affects billing compliance is obtained. The box under the Calendar Version will always show an Eff. Date to indicate when this version became effective. You will use the most recent calendar version (highest version number) that falls on or before your date of service. For example, calendar version 3 shows Eff. Date 6/25/24. The date of service on your charge is 6/2/24. You will need to toggle the Calendar Version back to Calendar Version 2, which has the Eff. Date of 5/20/24.
2. If the calendar has more than one Arm, you will see a Protocol arm field. You can filter this to the Arm you noted for the subject earlier.
3. Always click the Display Event Codes and Item Codes box and hit Submit.

OnCore Billing Grid

The billing grid is composed of a list of study activities/ procedures (treatments, tests, etc.) required by the protocol down the left side and the visit schedule across the top in a table format. A billing designation will appear in each box where the procedure and visit intersect. A coverage analyst will assign charge master events (cpt codes and descriptions) to the procedures and will assign the billing designation and additional information when applicable.

A PRN visit is added near the beginning of the billing grid timeline (shown in screenshot of the Billing grid below) and will contain any procedure that could be done outside of a scheduled visit that should be billed to the study. Study coordinators are trained to add the procedure as an additional procedure when it is done during a scheduled visit. They are trained to add an Additional visit when they are done outside of a scheduled visit. For both scenarios, you will refer to the billing designation in the PRN visit.

Billing Designations: S also known as Standard of Care or SOC R also known as Research	Supporting Designations:

Billing Designations:

S also known as Standard of Care or SOC
R also known as Research

Supporting Designations:

For SOC services, the coverage analyst will assign a Q modifier and a cpt code/s when the service will require the modifier and research diagnosis code Z00.6 on the claim form. You will sometimes see a billing grid with an S billing designation without those things (0 or 1 and or cpt codes) when the study team prefers they stay in the billing grid for purposes outside of billing compliance. These will be billed as SOC-not study related.

Scroll down to the bottom of the calendar and click Expand All. This can make the procedure list very long, but we recommend you do this and then do Ctrl F to find your cpt code. We recommend this because the codes may not always be under the procedure you would expect them to be under. For example, for tumor biopsies, you will often find the surgery code, radiological guidance codes, anesthesia codes, and pathology codes.
After Expanding
1. If you don’t find your code:
  1. Look at the list of code descriptions to see if you have a close match. Protocols are not always as detailed as to what is required or what may be done, in terms of how specific cpt coding can be. For example, the protocol may require an “unattended sleep study” (95800). But if there is a clinical indication to do a sleep study attended by a technologist (95807), they will likely not do both. You would likely see the 95800 in the billing grid and not the 95807. If you have a close match such as this, you should consider it study related and bill according to the billing grid.
  2. Look for a code range that your code fits within. For example, for the more common services where we are aware that variations of a service might be performed, we include a code range/s. For example, the protocol might require a physical exam, but we know that E/M codes will vary by medical necessity and could fall under a range of codes. If you do a CTRL F for 99213, you will not find the code. However, by looking manually, you will find the code range 99211-99239 .
2. If you do not find the visit name on the billing grid, refer to the footnotes to find a visit where billing will match the visit on the subject calendar. For example: if you are looking for visit C6D1 but the Calendar and Billing Grid only show until C4D1, you can see in the footnote below, that it should be billed the same as visit C4D1. *Keep in mind that only the TBD and oe footnotes should be used for billing compliance.
When you find a service description in the visit field that matches or is close to your CPT code then use this table to determine the billing

Designation	Conditions	Bill as	Example in Expanded Billing Grid Screenshot above

Designation	Conditions	Bill as	Example in Expanded Billing Grid Screenshot above
S	no CPT codes no “0” or a “1” behind the S (S1) service is not a drug name	SOC, not study related	Venipuncture (1)
S	no CPT codes service is a drug name	SOC, study related - Look for the 0 or 1 but you will not see HCPCS codes.	Capecitabine (2)
S	has a “0” or a “1” behind the S (S1 ) has cpt codes	SOC, study related	FSH (3)
R	no CPT codes Supporting Designation of CL, DRA or PBS	SOC, not study related	ECHO/MUGA (4)
R	no Supporting Designation has cpt codes	Research	Coagulation (5)
R	Has CPT codes Supporting Designation of TBD SOC box is not checked on subject calendar	Research	Brain Imaging (6)
R	Has CPT codes Supporting Designation of TBD SOC box checked on subject calendar **TBD services will not have the 0 or 1 modifier	SOC, study related unless the TBD footnote indicates to bill it as SOC, not study related.	Tumor Assessments (7)
R	Only appears in the PRN Visit	Research, but may want to confirm with study team

Troubleshooting

If you have subject specific questions or suspect the coordinator did not check in a visit at all or incorrectly, go to the PC Console. Click on the Staff tab at the top. Sort by Role and look for the Clinical Research Coordinator-Primary role. You can hover over the name to obtain the email address for this person who can answer your questions.
If you have questions about the billing grid, look for the WU Coverage Analyst role and email them with those types of questions.
If the study is noted to have No billing risk in Epic, but the order/encounter indicates it is study related, contact the WU Coverage Analyst.