CY2013 Outpatient Itemized Billing (OIB) Rates Update

1. CY2013 Outpatient Itemized Billing (OIB) Rates Update Presented by TMA UBO Program Office Contract Support 18 June 2013 0800-0900 EDT 20 June 2013 1400-1500 EDT From your computeror Web-enabledmobile devicelog into: http://altarum.adobeconnect.com/ubo.  Enter as a guest, then enter your name plusyour Service affiliation (e.g., Army, Navy, Air Force) for your Service to receive credit. Instructions for CEU credit are at the end of this presentation. [Note: The TMA UBO Program Office is not responsible for and does not reimburse any airtime, data, roaming or other charges for mobile, wireless and any other internet connections and use.] Listen to the Webinar by audio stream through your computer or Web-enabledmobile device. To do so, it must have a sound card and speakers. Make sure the volume is up (click “start”, “control panel”, “sounds and audio devices” and move the volume to “high”) and that the “mute” check box is not marked on your volume/horn icon. If you do not have a sound card or speakers or have any technical problems before or during the Webinar, please contact us at webmeeting@altarum.orgso we may assist and set you up with audio. You may submit a question or request technical assistance at anytime by typing it into the “Question” field on the left and clicking “Send.”

2. Agenda OIB Overview General Methodology CMAC/CMAC Component Rates Other OIB Rates MEPRS Based Rates Mapping Table Updates Rates Questions Received via the UBO Helpdesk

3. OIB Overview • TMA UBO develops rates for each outpatient encounter, service, procedure, or supply provided within a MTF • Rates are billed as a line-item charge • Rates are the charges for both professional and institutional services • Rates are used to submit claims for reimbursement according to the MTF Cost Recovery Programs • TMA UBO rates consists of • CHAMPUS Maximum Allowable Charge (CMAC) • Medical Expense and Performance Reporting System (MEPRS) data • Other OIB Rates

4. Effective Date CY 2013 OIB Rate Package in conjunction with Elective Cosmetic Procedure Rates are scheduled to be effective 1 July 2013.

5. General OIB Rate Methodology • Gather inputs for rate calculations • TRICARE data downloads • Perform Rate Calculations • Data Pulls and Analysis • Calculate average costs for MEPRS based rates • Apply to appropriate rate tables • Develop rate mapping tables • TMA UBO Program Office approval • Deliverables for Review and Testing • Internal QA and Testing • Forward to TMA UBO, TPOCS and CHCS • UBO Policy letter development • Distribution and Publication

6. OIB Components • CMAC & CMAC Component Rate Tables • Other (APV, Observation, ED) • Ambulance • Anesthesia • Dental • Durable Medical Equipment/Supplies (DME/DMS) • Immunization/Injectables • IMET/IOR Government Discounts • Mapping Tables (DMIS ID, Revenue, TPOCS, Modifier)

7. Overview – CMAC and CMAC Component Rates OIB Primary Rate Tables – CMAC and CMAC Component • 91 CMAC localities • CMAC locality ‘300’ – TMA UBO specific and used for the national average of CONUS facilities • CMAC locality ‘391’ – TMA UBO specific and used for OCONUS facilities • .90% overall average percent increase from CY2012 to CY2013 The Component rate table specifies the technical (TC) and professional (PC) components and/or the combined technical and professional service for CPT® codes. • For codes that CMAC did not provide rates for – added technical charges • *Not available for separate reimbursement

8. CMAC Emergency Department Rates Emergency Department (ED) • Evaluation & Management Codes (99281-99285) • Hospital level (1-5) ED visits • Can only bill the institutional charge • Mapped to the UB-04 billing form

9. Other OIB Rates Anesthesia Durable Medical Equipment/Supplies (DME/DMS) Immunization Observation

10. Other OIB Rates – Anesthesia and DME/DMS Anesthesia • TRICARE Anesthesia Reimbursement Formula (Time Units + Base Units) X National Average Conversion Factor • 2013 NACF = $21.92 • Average percent increase = 2.41% DME/DMS • Expenses allocated for equipment and supplies on hand • Used CMS 2013 DMEPOS Fee Schedule file - ‘floor rate’ • Used purchased care data to develop rates for existing DME/DMS procedures without a CMS provided rate or a rate of $0.00. • No major price variances from 2012 to 2013 • Average percent increase = 5.35%

11. Other OIB Rates – Observation Observation • Ambulatory services performed within the hospital’s ED or nursing unit • Charges based on CMS Observation Payment Factor • Capture both institutional and professional components • Captures the number of hours a patient is in Observation • PC Calculation: CMS Payment Factor divided by the average DoD hours a patient is in the OBS unit • DoD Average OBS encounter = 9.7 hours

12. MEPRS-Based Rates MEPRS REMINDER Ambulance Ambulatory Procedure Visit (APV) Dental Immunization-specific IOR/IMET (Government Discounts %) *Represents less than 2% of all OIB Rates

13. MEPRS-Based Rates Recoup depreciation & interest costs Retirement, health benefits and life insurance Pay raise percentage - presidential budget Military medical personnel salary expenses Percentage growth in budget Computation and Burdening Factors Asset Use GSUR Costs Military Pay Civilian Pay ‘DMDC’ Factor DHP Growth

14. MEPRS-Based Rates Computation and Burdening Factors 20122013 Asset Use 4.40% 4.40% GSUR Costs 9.90% 9.90% Military Pay 1.60% 1.70% Civilian Pay 0.00% 0.00% ‘DMDC’ Factor $(4) $8* DHP Growth 6.48% 5.05% *DMDC number calculated by averaging the factor from the previous two years. However the 2012 factor was recalculated producing $4 instead.

15. MEPRS-Based Rates Cost to Be Recovered = MEPRS Full Rate x Time Ambulance • Charges are based on units of service, in 15-minute increments • Ambulance is billed using A0999 (unlisted code) Ambulatory Procedure Visits (APVs) • Flat institutional fee based on the institutional cost of all APVs performed in a designated Ambulatory Procedure Unit (APU) divided by the total number of APVs • Assigned to CPT® code 99199 • 2013 APV Flat Rate is $2,262.97

16. MEPRS-Based Rates Charge = Weight * Rate (IMET/IOR/FOR) Dental • Charges based on a MEPRS-based flat rate multiplied by a DoD-established weight for the American Dental Association® (ADA) code representing the dental service/procedure performed * Used 2013 DoD Dental weights IMET/IOR rate • Government adjusted discounts for interagency cost of supplies (IOR) and direct labor for the training programs (IMET) • Discounts are applied to the Full Outpatient Rate (FOR)

17. Immunization CMAC – TRICARE Provided Rate Immunization - separate charges are made for each immunization, injection or medication administered 2013 Immunization MEPRS-Based Flat Rate = $50

18. MEPRS-Based Rates – Rate Comparisons MEPRS REMINDER Represents less than 2% of all OIB Rates

19. Mapping Tables DMIS ID Mapping Table Revenue Mapping Table TPOCS Mapping Table Modifier Mapping Table

20. Mapping Tables New for 2013 DMIS ID • Defense Medical Information System Identifier Table is the controlling standard for both medical and military facility identification and cost/workload classification. • 8 New DMIS IDs since CY2012 update • 1 Affects UBO billing (including OCONUS) • Mapped all OCONUS sites to “391” • Facility type changes • 198 total changes • 10 Affects UBO billing (including OCONUS) • ADMIN to INACTIVE; HOSP to INACTIVE; CLNC to INACTIVE • Mapped 53xx-54xx series to designated locality codes • Civilian institutions bills a facility fee; • MTFs bill professional fees only

21. Mapping Tables Revenue Mapping Table • Identifies the CPT®/HCPCS procedure, supply, drug code, description and available revenue centers. • Added/deleted/revised and provided proper revenue code designation for all active codes • Used default 510 (clinic) revenue code where no revenue center was indicated TPOCS Mapping Table • Identifies the CPT®/HCPCS procedure, supply, drug code, and description with appropriate modifiers. • Specifically designed for the TPOCS billing environment • Updated code series, ranges and applicable modifiers • Verified mapping to appropriate tables Modifier Mapping Table • Identifies the CPT®/HCPCS procedure, supply, drug code, and description with appropriate modifiers. • Includes mapping to appropriate OIB table • Determines which modifiers are appended to which code ranges • Released January 2013, No July update

22. Rate Questions Received via UBO Helpdesk

23. Rate Questions Receivedvia UBO Helpdesk • Where are the TRICARE CMAC rates? I do not see them on the UBO Web site. • TRICARE CMAC rates are available on the TRICARE.mil Web site and are used to recover the cost of healthcare services provided by MTFs that abides by DoD/VA Resource Sharing agreements. These rates are different than the TMA UBO CMAC rates which are based on TRICARE CMAC rates, but are formatted for military billing systems and include charges for additional services not reimbursed by TRICARE • Where can I find MAC billing rates from previous years? • MAC rates are available on the TMA UBO website at: https://tricare.mil/ocfo/mcfs/ubo/mhs_rates/mac.cfm. There is also a link to archived MAC rates on that page. Select the rates effective on the date of service. • Regarding rates listed in CHCS, who does the update and when is it done? • Outpatient rates are loaded into CHCS to be effective 1 July. Inpatient rates are loaded into CHCS to be effective 1 October. Contact your Service UBO Program Manager and your CHCS administrator if you believe the rates are incorrect or have not been loaded.

24. Rate Questions Received via UBO Helpdesk • If we find a code that is not in the Durable Medical Equipment (DME) table, how do we get a code added? • If you have a DME code that is not in the applicable rate table for the date of service in question, send an e-mail to the UBO.Helpdesk@altarum.org with the specific code information and date of service in question. We will research whether there is or should be a rate for that code. • If the patient’s date of service was CY 2012, but we are filing the claim in CY 2013, what codes are used? • Use the CPT®/HCPCS codes that are effective on the date of service. • What do I do if a claim is denied because the code has been deleted or an incorrect code was used? • If a code is deleted, the effective date of the replacement code(s)/rates will determine if the denial is valid . • New OIB codes effective rates for TMA UBO is 1 July, annually • If an incorrect code is used, billers should not change the codes, but work with the coding department to determine a better/correct code to be used AND the code must be effective on the date of service.

25. Rate Questions Receivedvia UBO Helpdesk • How are billing forms mapped in TPOCS? • Billing forms are based on where the services are provided. In our current billing environment we can only bill institutional or professional charges, not both. Currently, reimbursement is higher for institutional charges within the DoD. • Is it possible to assign CMAC localities to the civilian institutions for billing purposes? • Yes, CMAC localities have been assigned to the civilian hospitals (DMIS IDs 53xx-54xx), so that MTFs can bill for the professional services provided at those institutions. The civilian hospitals may bill their own institutional charges. • How to apply rates for immunization code, J1745? The rate provided is around $58 but there is no indication in TPOCS on the unit of issue. • For HCPCS Code J1745 - the unit of measure is 10MG. The current rate for HCPCS code J1745 is $63.53, effective until 30 June 2013. For other dates of service, please refer to the associated Immunization file for applicable rates. • The actual charge would be the rate (per date of service) multiplied by total quantity injected (in MG) divided by 10.

26. Rate Questions Received via UBO Helpdesk • On the UBO website the Revenue mapping table indicates an RV1 (Column D), RV2 (Column E), RV3, RV4, RV 5, and RV6. What do these levels represent when it comes to determining which revenue code to use? Example, Code 99143 has 5 revenue codes listed, which one would be correct when billing on a UB04? • In the RMT, each CPT®/HCPCS code have the option of six applicable revenue centers for place of service. The revenue center in the first position is the most common. The other revenue centers are other possibilities as to where the service can be provided. The user can choose accordingly per their situation. • How can additional revenue centers be assigned to the CPT®/HCPCS codes in the Revenue Mapping Table? • If an additional revenue center needs to be assigned or one needs to be changed, contact your Service UBO Program Manager THEN submit a UBO helpdesk ticket via ubo.helpdesk@altarum.org. We will research and update/correct as needed.

27. Contact Info Please contact the UBO Helpdesk if you have any questions or concerns at (571)733-5935 or UBO.helpdesk@altarum.org.

28. Thank you

29. Instructions for CEU Credit This live Webinar broadcast has been approved by the American Academy of Professional Coders (AAPC) for 1.0 CEU credit. Granting of this approval in no way constitutes endorsement by the AAPC of the program, content or the program sponsor. There is no charge for this credit, but to receive it participants must login with their: 1) full name; 2) Service affiliation; and 3) e-mail address prior to the broadcast. If more than one participant is viewing the Webinar on one computer or mobile device, then the names and e-mail addresses of each participant who wishes to receive CEU credit must be entered into the Q&A pod below the presentation screen. If a participant cannot login and requires a dial in number to hear the Webinar, then for CEU credit he/she must e-mail the UBO.LearningCenter@altarum.org within 15 minutes of the end of the live broadcast with “request CEU credit” in the subject line. Participants must also listen to the entire Webinar broadcast. At the completion of the broadcast, the Certificate of Approval with Index Number will be sent via e-mail only to participants who logged in prior to the broadcast and provided their full name and e-mail address as required. Participants may also view and listen to the archived version of this Webinar—which will be posted to the TMA UBO Learning Center shortly after the live broadcast--for one (1.0) AAPC approved CEU credit. To receive this credit, after viewing the archived Webinar, they must complete a ten (10) question minimum post-test that will be available on the TMA UBO Learning Center and submit their answers via e-mail to ubohelpdesk@altarum.org. If at least 70% of the post-test is answered correctly, participants will receive via e-mail a Certificate of Approval with Index Number.

30. Instructions for CEU Credit, cont. Participants may not alter the original Certificate of Approval. CEU certificates should be maintained on file for at least six months beyond your renewal date in the event you are selected for CEU verification by AAPC. For additional information or questions, please contact the AAPC concerning CEUs and its policy.

31. Other Organizations Accepting AAPC CEUs Participants certified with the American Health Information Management Association (AHIMA) may self-report AAPC CEUs for credit at https://secure.ahima.org/certification/ce/cereporting/. The American College of Healthcare Executives (ACHE) grants one (1.0) Category II ACHE educational credit hour per one (1.0) hour executive/management-level training course or seminar sponsored by other organizations toward advancement or recertification. Participants may self-report CEUs on their personal page at http://www.ache.org/APPS/recertification.cfm. The American Association of Healthcare Administrative Managers (AAHAM) grants one (1.0) CEU unit “for each hour in attendance at an educational program or class related to the health care field” for AAHAM-credentialed participants who self-report using AAHAM’s on-line CEU tool. Participants may self-report CEUs during their recertification process at http://www.aaham.org/Certification/ReCertification/tabid/76/Default.aspx.