I. WashU Billing Staff

After you have clicked on the patient you are reviewing in Epic, take note of the following for the charge you are reviewing:
1. CPT Code,
2. Description of Service
3. 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 not at all, use the Billing Matrix for charge segregation.
2. If this is marked Yes, then go to OnCore.
In OnCore, there are 3 tabs in 3 different Consoles that you should "star” (similar to a bookmark) for frequent use. See screenshot below on how to star tabs. You will only have to do this once.
1. CRA Console Visit Calendar- to get specific patient visit date information and TBD clarifications
2. Coverage Analysis Billing Grid- for charge segregation source of truth
3. PC Console- to view the Staff list
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 so that patients who have consented but may have been ineligible for the study after screening will show.
2. Note Headers: Note all Column Headers, IE: Arm, Status, Status Date, Last Visit, Last Visit Date
3. You can sort this view by MRN or name.
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 the Note under #7 below for instructions on how to toggle between arms.
Once you find your patient in the list, you will now click on the patient’s Epic MRN, and will be directed to the demographics page for that patient.
On the left vertical menu, scroll down and click on Calendar. This is the patient specific calendar that will show visit dates, but not billing designations.
1. To help navigate this page, click on the Freeze Panes box on the top left of the calendar.
2. 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).
  1. Keep in mind that sometimes services related to a study may occur on a different date, usually in close proximity to the occurred visit date. You will see how to check for these variations later.
  2. Coordinators are instructed to update the Patient Visit Calendar within 2 business days of the visit occurring. If you have a service that matches a date that has passed, but is near the Planned Date, you may contact the coordinator to avoid a billing error. This will be good reinforcement for them so that they grow to understand the importance of this.
  3. If you do not see the Visit Date that you are looking for, please check the Orphaned Visits tab next to the Calendar tab below. If a Visit is removed when a new Calendar Version is created, 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.
3. Now look down the list of procedures and locate the service you are reviewing. Note that there are two gray scroll bars at the right of the screen. Make sure you are seeing the whole list.
4. Take note of the Visit Name for that date of service (circled in the screen shot above). This will be identical to the visit name on the Billing Grid in a later section.
5. Click on the visit name hyperlink that matches the date of service for the charge you are reviewing.
  1. Below where it says Procedures (circled in screen shot below) click on Expand All to see a list of services that occurred for that subject on or near that date.
    1. If all services occurred on the visit date, they will all default to the date entered.
    2. If the procedure occurred on a different date than the rest of the visit, the coordinator is instructed to indicate this in the box next to the procedure.
  2. Note(!) the box marked SOC is NOT the source of truth for charge segregation except in the case of a TBD service
  3. Note (!!) Additional procedures that occur on or near a planned Visit will appear in the list. HOWEVER, additional Visits (unplanned) will not show on this patient calendar. These are expected to be recorded in an Additional Visit. if you do not find the date of service of your charge on the subject calendar, click on the Additional Visits tab under the Calendar tab (see above screen shot). Always check the Billing Grid in the Coverage Analysis Console to see if the service you are reviewing is listed in a PRN column. In this case, you should always bill as instructed in the Billing Grid regardless as to whether you see a visit date recorded for a specific patient.
  4. Note (!!!) If a patient is on more than one arm, you can switch arms at the bottom left of the Subject calendar.
This is where starring your most commonly used tabs is useful. Go to the Coverage Analysis Console and click on Billing Grid in the vertical menu on the left.
1. If there is more than one Calendar Version, you will see a Calendar Version field. The Billing Effective date is listed beside it.
2. If the date of service for the charge you are reviewing is before the Billing Effective date, you will click the dropdown to select the Calendar Version in which the date would have fallen.
In the top right corner, check the box that says “Display Event Codes and Item Codes” then click Submit. If the study has arms, you can filter by the Protocol Arm you saw listed for your patient. Scroll down to the bottom of the calendar and click on “Expand All” to see all of the services and CPT codes included. At the top left of the billing grid, there is a Freeze Panes button that you can click on to scroll.
1. Keep in mind that research protocols do not always list required services to the level of specificity that some CPT codes are written. If the service name you are looking at is similar to a service name that has at least one CPT code in this list, but you do not see the exact CPT code, investigate further by looking at notes in Epic or contacting the “Clinical Research Coordinator- Primary” on the Staff tab (this is a horizontal tab on the Main page of the PC Console).
  1. For example, if the service you are looking for is an "EEG: Routine" CPT 95812, but you only see an "EEG: Long-Term" CPT codes 95700-95726 on the OnCore grid, you may check with the coordinator to see if this service was done in its place.
  2. For a protocol requiring a tumor resection that could be anywhere in the body and would require more codes than the system is capable of holding, you will just see the name of the service and no cpt codes.
2. Locate your service from the vertical list and match it to the visit name on the horizontal tab.
Once you match up your service with your time frame, you will see an ‘R’ or an ‘S’ to indicate how the service should be billed. These are the Billing Designations. OnCore also allows for Supporting Designations. The Coverage Analyst will add these for all services to be billed to insurance and some services that should be billed to the study.
1. S1 means that procedure will be billed as standard of care with the Q1 modifiers. S = standard of care and 1 = add Q1 modifier (Modifier Type: Routine)
2. S0 means that procedure will be billed as standard of care with the Q0 modifiers. S = standard of care and 0 = add Q0 modifier (Modifier Type: Investigational/Device)
3. R means that the procedure should be billed to the study
  
  **Note that services listed in the OnCore without CPT codes but are labeled as S with no 0 or 1 modifier should be billed as SOC, not study related. This means that the study does not meet Medicare's clinical trial policy (NCD 310.1) and the charges should not go out with Q modifiers.
The supporting designation of “DRA” or “CL” indicate that the study team has told us that these services will not be occurring in a clinical area where there is billing risk for Washington University or BJC Hospitals. If you have a charge that matches the date of service, you may want to investigate further with the coordinator to determine if this was study related. If you find that it is study related, please reach out to Kelly Granda (grandak@wustl.edu) so that the billing grid can be updated for future charges.
1. R(DRA) indicates that the service will be performed in a designated research area with no billing risk for that service.
2. R(CL) indicates that the lab will be performed at a central lab and there will be no billing risk for that service.
3. The key below will be on every OnCore Billing Grid for your reference.
For services that will sometimes be billed to the study and sometimes billed to insurance, the coverage analyst will default the billing designation to R with a “TBD” supporting designation R(TBD) and a footnote R^TBD. When you see this for the charge you are reviewing, you will go back to the Subject Calendar in the CRA Console to see if the coordinator has marked the SOC box for the service.
1. If this box is marked, you will bill to insurance.
2. If it is not, you have two options:
  1. Bill the procedure to the study or
  2. If the order/encounter was not associated to the study and marked bill to study in Epic, you may contact the coordinator to verify how the procedure should be billed.
Once all these items have been reviewed and you know how service should be billed, you go back to your Epic work queue and complete the billing for that service.