Briefing: Hands-on UB-04 Manual Billing DoD

1. 1 Briefing: Hands-on UB-04 � Manual Billing & DoD/VA Resource Sharing Example Date: 20 March 2007 Time: 1610 - 1700

2. 2 Objectives Understand that there is new billing guidance for inpatient care provided under VA/DoD Health Care Resource Sharing Agreements Understand that the Modified TRICARE DRG Payment Calculator is used calculate payment due for hospitalization, but it does not produce billing documents Understand how to use the UB-04 in billing for VA/DoD Health Care Resource Sharing

3. 3 Brief History of DoD/VA Sharing Federal Health Resource Sharing Legislation (1980-1981) Encouraged interagency sharing and creativity in development of agreements Veterans Administration and Department of Defense Health Resources Sharing and Emergency Operations Act Public Law 97-174 (1983) Encouraged continuation and expansion of resource sharing Resulted in 1983 Memorandum of Understanding (MOU) between DoD and VA on sharing, which says the rate will take into account local conditions and actual costs National Defense Authorization Act (NDAA) of 2003 Title 38, Section 8111 and Title 10, Section 1104 Established Joint Executive Council for governance Encouraged DoD and VA joint strategic planning Mandated standardized reimbursement rates for DoD/VA sharing DoD Instruction 6010.23, 12 Sep 2005 Department of Defense and Department of Veterans Affairs Health Care Resource Sharing Program

4. 4 Overarching Goals for DoD/VA Sharing Goal 1 � Leadership Commitment and Accountability Goal 2 � High Quality Health Care Goal 3 � Seamless Coordination of Benefits Goal 4 � Integrated Information Sharing Goal 5 � Efficiency of Operations Goal 6 � Joint Medical Contingency/Readiness Capabilities

5. 5 DoD/VA Reimbursement Methodology will be agreed to by both departments Not the same as billing DoD Third Party Collections (TPC) program Not using Interagency Rates (there are a few exceptions) Provide flexibility to take into account local conditions and actual costs Actual cost is defined as direct, incremental cost Does not equal MEPRs cost, which is a fully loaded cost Both departments have been criticized in the past by GAO for not using incremental costs Funds will be credited to the providing facility �Continued�

6. 6 DoD/VA Reimbursement Per NDAA - 2003, rates will be standardized and waivers are allowed 2003 DoD/VA Memorandum of Agreement (MOA) � established basic agreement to use price-based methodology of discounted CHAMPUS Maximum Allowable Charge (CMAC) and TRICARE DRG-based rates 2003 MOA states that there will be no additional reimbursement to cover costs of Graduate Medical Education (GME) in direct sharing agreements (includes both direct and indirect GME) Joint ventures may adjust the discount rate depending on local sharing arrangements Joint venture rates can be lower than the standard rates, but not higher Standardized methodology is used for care direct sharing agreements only and does not apply for care provided by VA facilities when they are acting as TRICARE network providers

7. 7 New Inpatient Billing Guidance Policy guidance developed by Financial Management Work Group and coordinated with DoD and VA Guidance document signed 29 August 2006 Requires Modified TRICARE DRG Payment Calculators to implement Implementation guidance and the FY 2007 payment calculators now available on UBO Web site at: http://www.tricare.mil/ocfo/mcfs/ubo/index.cfm

8. 8 New Inpatient Billing Guidance DoD/VA 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 Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), and Blind Rehab cases will not fall under this methodology Apply to all inpatient sharing agreements, including joint ventures Allow for additional payment for cases which involve outlier days (e.g., long-stay cases) Do not bill for costs associated with Graduate Medical Education or Capital Expense Equipment Apply to existing and new DoD/VA sharing agreements Incorporate new methodology into new agreements and renewal or renegotiation of existing agreements Must be implemented by one year from date of agreement

9. 9 Implementation for Inpatient Billing Use 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 Use Healthcare Common Procedure Coding System (HCPCS) for non-institutional (professional and other services) not included in DRG-based payment

10. 10 Data Sources and Flows 92502-92526 Special Otorhinolaryngologic Services 92531-92548 Vestibular Function Tests 92551-02597 Audiologic Function Tests92502-92526 Special Otorhinolaryngologic Services 92531-92548 Vestibular Function Tests 92551-02597 Audiologic Function Tests

11. 11 Case Description A veteran who has post-traumatic stress disorder, and who is prescribed anti-convulsant medication, had an accident at home as a result of suffering an episode of convulsions The veteran presented at the MTF Emergency Room, was treated in the ER, and was admitted to the hospital The hospitalization lasted three days and the patient underwent two CAT scans during that time The patient was discharged to home

12. 12 Coded Case Data � Hospitalization Patient DOB: 02/27/1946 Patient Sex: Male ER Visit Date: 02/18/2006; Disposition Status = Admitted Admission Date: 02/19/2006 Discharge Date: 02/22/2003; Disposition Status: Discharge to Home Principal Diagnosis: 78039 CONVULSIONS, NEC Secondary Diagnoses 3343, CEREBELLAR ATAXIA NEC E9363, ADV EFF ANTCNVL NEC/NOS E8490, ACCIDENT IN HOME 4019, HYPERTENSION NOS 6929 DERMATITIS NOS 30981 POSTTRAUMATIC STRESS DS 3659 GLAUCOMA NOS Procedures Performed 8741 C.A.T SCAN OF THORAX 8801 C.A.T. SCAN OF ABDOMEN DRG: 025, SEIZURE & HEADACHE AGE > 17, W/O CC

13. 13 Coded Case Data � Professional Services ER Visit Date: 02/18/2006; Disposition Status = Admitted; Dr. Axxx, Plus 2 others Primary Diagnosis: 34590 EPILEP NOS W/O INTR EPIL Secondary Diagnosis: 7804 DIZZINESS AND GIDDINESS Procedures: 99824, J7030, J2405, J3360 First Hospital Day: 02/19/2006; Dr. Bxxx, Plus 1 other Primary Diagnosis: 78039 CONVULSIONS, NEC Secondary Diagnoses: 4019, HYPERTENSION NOS; V155 HX OF INJURY Procedure: 99222 Second Hospital Day: 02/20/2006; Dr. Bxxx, Plus 2 others Primary Diagnosis: 78039 CONVULSIONS, NEC Secondary Diagnoses: 4019, HYPERTENSION NOS; V155 HX OF INJURY Procedure: 99233 �Continued�

14. 14 Coded Case Data � Professional Services Third Hospital Day: 02/21/2006; Dr. Cxxx Primary Diagnosis: 34590 EPILEP NOS W/O INTR EPIL Procedure: 99499 Day of Discharge: 02/22/2006; Disposition Status = Discharge to Home; Dr. Bxxx, Plus 2 others Primary Diagnosis:9663 POIS ANTICONVL NEC/NOS Secondary Diagnoses: 78039 CONVULSIONS NEC; E8550 ACC-POISN ANTICONVULSANT; 4019 HYPERTENSION NOS Procedure: 99238

15. 15 Modified TRICARE DRG Payment Calculator Inputs DRG Length of Stay (LOS) Disposition Status (Code) Area Wage Index Number Output Amount to be billed, with 10% discount already calculated

16. 16 Modified TRICARE DRG Payment CalculatorOverview of Inputs & Output The TMA UBO Support Contract Team is now on the list of offices who receive the updated table. We do not anticipate a delay in loading this table in the future. Clarification - ICD-9 codes will now be available for use on the bill form to support the CPT-4 assignment in Third Party Billing.The TMA UBO Support Contract Team is now on the list of offices who receive the updated table. We do not anticipate a delay in loading this table in the future. Clarification - ICD-9 codes will now be available for use on the bill form to support the CPT-4 assignment in Third Party Billing.

17. 17 Modified TRICARE DRG Payment CalculatorSummary of Inputs for This Case Inputs DRG = 025 Length of Stay = 3 days Disposition Status Code = 01 (Home, Self Care) Area Wage Index Number = 0.8945 Output Amount to be billed, with 10% discount already calculated = $2,357.33

18. 18 Modified TRICARE DRG Payment CalculatorCase-specific Inputs and Outputs The TMA UBO Support Contract Team is now on the list of offices who receive the updated table. We do not anticipate a delay in loading this table in the future. Clarification - ICD-9 codes will now be available for use on the bill form to support the CPT-4 assignment in Third Party Billing.The TMA UBO Support Contract Team is now on the list of offices who receive the updated table. We do not anticipate a delay in loading this table in the future. Clarification - ICD-9 codes will now be available for use on the bill form to support the CPT-4 assignment in Third Party Billing.

19. 19 Using the UB-04 For Billing

20. 20

21. 21

22. 22

23. 23

24. 24

25. 25

26. 26

27. 27

28. 28

29. 29

30. 30

31. 31

32. 32 Summary New 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 be used to calculate of amount to be billed for institutional component of service FY2006 and FY2007 calculators and billing guidance documents now available on the UBO Web site For MTFs, this new policy is likely to involve manual billing until the Charge-Master Based Billing (CMBB) system is implemented The UB-04 will soon be available for use in that manual billing process Issue was that TRICARE only provided a CMAC Component rate for provider class 1. Therefore, no T.C. or 26 modifiers were being allowed to bill. There was no provider class 4 rate available All Class 4 rates are identical as the Class 1 rates within their respective locality MHS Helpdesk Trouble tickets were submitted by: Navy Grotton and Army Ft. Hood Full list of Codes added are: 92552, 92553, 92555, 92557, 92561, 92562, 92563, 92564, 92565, 92567, 92568, 92569, 92571, 92572, 92573, 92575, 92576, 92577, 92579, 92582, 92583, 92584, 92585, 92586, 92587, 92588, 92596 92502-92526 Special Otorhinolaryngologic Services 92531-92548 Vestibular Function Tests 92551-02597 Audiologic Function TestsIssue was that TRICARE only provided a CMAC Component rate for provider class 1. Therefore, no T.C. or 26 modifiers were being allowed to bill. There was no provider class 4 rate available All Class 4 rates are identical as the Class 1 rates within their respective locality MHS Helpdesk Trouble tickets were submitted by: Navy Grotton and Army Ft. Hood Full list of Codes added are: 92552, 92553, 92555, 92557, 92561, 92562, 92563, 92564, 92565, 92567, 92568, 92569, 92571, 92572, 92573, 92575, 92576, 92577, 92579, 92582, 92583, 92584, 92585, 92586, 92587, 92588, 92596 92502-92526 Special Otorhinolaryngologic Services 92531-92548 Vestibular Function Tests 92551-02597 Audiologic Function Tests

33. 33 Q&A Questions? Please continue to use the MHS Helpdesk, the TMA UBO Helpdesk, and/or contact us directly: 703-575-5385 or at ubo.helpdesk@altarum.org Please remember the TMA UBO Web site, it has a lot of information available Including the Modified TRICARE DRG Payment Calculators used in determining the amount to be billed for hospitalization under VA/DoD Health Care Resource Sharing Agreements

34. 34 Quiz What is the basis for payment of inpatient institutional care under the new VA/DoD Inpatient Billing Guidelines for care provided under VA/DoD Health Care Resource Sharing Agreements? Where are the payment calculators and implementation guidance posted? What is the name/number of the new form that can be used to support MTF manual billing of hospitalization care provided under VA/DoD Health Care Resource Sharing Agreements?