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Briefing: VA Payment Issues Date: 20 March 2007 Time: 1400 - 1450

Briefing: VA Payment Issues Date: 20 March 2007 Time: 1400 - 1450. Objectives. Review the Billing Guidance for inpatient and outpatient care provided under VA/DoD Health Care Resource Sharing Agreements

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Briefing: VA Payment Issues Date: 20 March 2007 Time: 1400 - 1450

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  1. Briefing: VA Payment Issues Date: 20 March 2007 Time: 1400 - 1450

  2. Objectives • Review the Billing Guidance for inpatient and outpatient care provided under VA/DoD Health Care Resource Sharing Agreements • Understand where to find the Modified TRICARE DRG Payment Calculator to calculate payment due for inpatient hospitalization

  3. VA/DoD Policy Guidance • VA/DoD Policy Guidance • Use CHAMPUS Maximum Allowable Charge rates, less a 10 percent discount, for institutional and professional charges • Apply to nearly all clinical services and specialties • Apply to all inpatient and outpatient sharing agreements, including joint ventures • Apply to existing and new VA/DoD Sharing Agreements • Any change in billing methodology MUST be approved

  4. Policy & Guidance • VA/DoD policy memorandum describes Inpatient Billing guidelines for inpatient care provided under VA/DoD Health Care Resource Sharing Agreements • Modified TRICARE DRG Payment Calculators will calculate of amount to be billed for institutional component of service • Calculators and billing guidance posted on the UBO Web site

  5. Rates • Diagnosis Related Group (DRG) payment approach for institutional (hospitalization) portion of inpatient care • Use Modified TRICARE DRG Payment Calculator to calculate amount to be billed • CPT-4 codes for outpatient care/services • Healthcare Common Procedure Coding System (HCPCS) for non-institutional (professional and other services) not included in DRG-based payment

  6. Billing Procedures • Billing is currently manual until the Charge Master Based Billing System (CMBB) is implemented • Billing venues now being used: • UB-92s and CMS 1450s • SF1080s with Excel spreadsheets

  7. Inpatient Billing • Diagnosis Related Groups (DRG) payment approach for institutional (hospitalization) portion of inpatient care uses modified TRICARE DRG Payment Calculator to calculate the amount to be billed • DRG • Length of Stay (LOS) • Disposition Status (Code) • Area Wage Index Number • VA/DoD Resource Sharing Policy parameters • Amount to be billed, with 10% discount, will be calculated

  8. Outpatient Billing • CPT-4 codes • Professional Services (E&M) • Procedures • HCPCS codes • Ancillary services • Labs • Rads (Professional & Technical components) • Pharmacy (Initial fills & refills) • Calculate amount to be billed with 10% discount

  9. Billing Responsibility • All VA billing should be done by the MSA Office • Any changes to the billing methodology or discount rate applied must be approved up the chain of command to TMA UBO • Justification for change must include a business case analysis

  10. Assistance • Use the MHS Helpdesk, the TMA UBO Help desk • The TMA UBO Web site, has a lot of information available • Report code/rate/mapping issues encountered: Those that must be fixed immediately and/or those that are requested to be considered for the next rate update

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