Presentation on theme: "Instructions for CEU credit are at the end of this presentation."— Presentation transcript:
1Instructions for CEU credit are at the end of this presentation. UBO USER GUIDE UPDATE Presented by DHA UBO Program Office Contract Support29 April – 09001 May – 1500For entry into the webinar, log into:Enter as a guest with your full name and Service or NCR MD affiliation for attendance verification.Instructions for CEU credit are at the end of this presentation.View and listen to the webinar through your computer or Web–enabled mobile device. Note: The DHA 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.If you need technical assistance with this webinar, contact us atYou may submit a question or request technical assistance at any during a live broadcast time by entering it into the “Question” field of Adobe Connect.
2Agenda Purpose of UBO User Guide Process and timelines Overview of Changes/Document Change HistoryNew layout and reorganizationKey changes in policy, procedures, and processesWrap-UpQuestions
3Purpose of UBO User Guide Track x – xxx day –UBO User Guide“provides functional guidance on data collection and Uniform Business Office (UBO) practices and billing procedures for Military Treatment Facilities (MTFs). This is a living document that is updated by the Defense Health Agency (DHA) UBO Program Office as necessary.”
4Update ProcessTrack x – xxx day –DHA UBO Program Office prioritized sections P1-P4 with UBO Advisory Work Group (AWG) review and opportunity to comment/inputDelete in-depth coding discussions and other verbiage not directly linked to billing and collectionsDelete outdated information and proceduresStandardize format/style, acronyms, definitions“rate”: the unit cost/price of a service/item“charge”: rate x quantity = total cost for that service/item“claim”: total charges submitted to payer for reimbursement“payer”: not insurance company
5Update Process, cont.Track x – xxx day –Standardize format/style, acronyms, definitions, cont.“claim format”: “UB-04/837I” and “1500/837P” not “paper claim”update all “ICD-9” references to “ICD-10” as applicableupdate all TPOCS references to “future billing system” as applicableReferencesDirect quotes from original source documents and consistent verbiage between sections used when possible to prevent differences in interpretationLanguage of Responsibility – for both clarification of intent and consistency of useShallMayWill
7Document Change History, Priority 1 Published 13 Dec 2013 Track x – xxx day –Added SectionsHelp Desk Support (formerly Appendix A – Helpdesk & Hotline Support)Billing Inpatient ServicesBilling Outpatient ServicesU.S. Coast Guard BillingVA-DOD Resource SharingBilling Appendix A – Procedure to Request DHA UBO Program Office-Approved Billing Rates for Services, Pharmaceuticals, or Durable Medical Equipment and Supplies Not Included in Standard Rate Files
8Document Change History, Priority 1 Published 13 Dec 2013, cont. Revised SectionsOverviewHelpful LinksAmbulatory Procedure VisitsDD7/DD7A Reports ProcessEmergency Department ServicesFile and Table MaintenanceLaboratory Services (Codes )Patient Categories (formerly Patient Administration)Pharmaceuticals (formerly Pharmacy Services)Pre-Authorizations/Pre-CertificationsProvidersRate TablesThird Party Collection Program – Report on Program Results (DD Form 2570)UBO Metrics Report
9Document Change History, Priority 1 Published 13 Dec 2013, cont. Track x – xxx day –Deleted SectionsBillable Encounters replaced with Billing Inpatient Services and Billing Outpatient ServicesInpatient Fiscal Year RatesOutpatient Services Not Related to InpatientAdmissions Technicians, Nurses, and “Incident To”Changed TMA to DHA in all sections except those that were not revised in this updateNote: Footer date is date of last User Guide review/change. Each section contains its last revision date.
10HIGHLIGHTS OF REVISIONS (published 13 DEC 2013) Track x – xxx day –HIGHLIGHTS OF REVISIONS (published 13 DEC 2013)
11Ambulatory Procedure Visits (APVs) (Revised) Track x – xxx day –Current revised version:Submit services of professional provider and anesthesia provider on professional claim format (1500/837P)Use 99199, which represents institutional component of an APV, and submit claim on institutional claim format (UB-04/837I)If admitted from an APV, do not charge for the institutional or professional services; they are included in the inpatient chargeAfter transition to future billing system, ABACUS:Do not use 99199Use Ambulatory Payment Classification (APC) charges for institutional costs at bedded MTFsUse Ambulatory Surgery Center (ASC) charges for institutional costs at nonbedded MTFsBill the professional, ancillary, DME, ambulance charges separately
12Billing Inpatient Services (New) Track x – xxx day –Current revised version:for TPC, MAC and most MSA, compute charges based upon MTF-specific ASAs which include cost of both inpatient institutional (93%) & professional (7%) chargesDo not bill separately for professional charges including if admitted from the emergency departmentFor inpatient services provided to USCG beneficiaries, USCG makes prospective payments to all Services and NCR MDDo not bill USCG; bill OHI, if anyBill non-Active Duty beneficiaries receiving inpatient services at the Family Member Rate (FMR) except:Family members of Active Duty members enrolled in TRICARE PrimeMembers whose OHI has been billed
13Billing Inpatient Services (New), cont. Track x – xxx day –After transition to future billing system, ABACUS:The MS-DRG payment will be based on the TRICARE ASASubmit, both, institutional UB-04/837I and professional 1500/837P claimsProspective payments to USCG continue; bill OHI onlyContinue to charge FMR as outlined in previous slide
14Billing Outpatient (New) and Emergency Department Services (Revised) Track x – xxx day –Current revised version:Rates are specific to an MTF’s locality and the Provider ClassRates for Emergency Department (ED) evaluation and management (E&M) codes represent institutional chargesCannot bill for ED professional services due to MHS system limitationsCannot bill for a service or supply if no rateConfirm with system administrator that the most current and updated version of rates files and tables have been loadedMay submit rate request using “Process to Request Out-of-Cycle DHA UBO Rates”
15Billing Outpatient (New) and Emergency Department Services (Revised) Track x – xxx day –After transition to future billing system, ABACUS:Rates will be specific to an MTF’s locality and the TRICARE Provider CategorySubmit both institutional and professional claims for ED E&M servicesUse 1500/837P for professional chargesUse UB-04/837I for APC-based institutional chargesCannot bill for a service or supply if no rateConfirm with system administrator that the most current and updated version of rates files and tables have been loadedMay submit rate request using “Process to Request Out-of-Cycle DHA UBO Rates”
16Billing US Coast Guard (New) USCG reimburses all Services and NCR MD annually with lump sum prospective paymentsDo not bill USCG except as noted belowCollect OHI and bill payersSubmit claims to USCG beneficiaries forPatient pay services (e.g., cosmetic surgery)Care provided to newborns of former USCG (PATCAT 28) or to newborns of sponsor’s daughters (PATCAT 29)Forward MAC claim information to USCG for its review and collectionDo not submit claims for USCG PATCAT C44 (USCG GAM MBR TRANSITIONAL COMP) or Medicare-eligible USCG beneficiaries
17VA-DOD Billing (new)Track x – xxx day –For PATCAT K61-2 patients (DOD/VA Sharing Agreement), follow national and local resource sharing agreement(s), if anyUse the DHA UBO Inpatient Institutional Calculator package effective on the patient’s date of serviceIncludes CHCS menu path to identify inpatient professional servicesUse the DHA UBO Outpatient Billing Guide effective on the patient’s date of serviceUse the DHA UBO VA-DOD Sharing Pharmacy Price Estimator (PPE) effective on the pharmaceutical fill dateFor K61-1 patients (Veterans Administration Beneficiary) follow Billing Inpatient and Outpatient Services
18File and Table Maintenance (Revised) and Pharmaceuticals (Revised) Track x – xxx day –Describes all UBO and non-UBO tables and files essential for accurate, up-to-date billingEnsure that the system administrator has received and downloaded the most current and updated versionsNew: Pharmaceutical rates package includes: Billers Edition information to translate dosage and unit measure prices and also TRICARE preauthorization listCannot bill if no rate for the NDC dispensedMay submit rate request to the DHA UBO Program Office using “Process to Request Out-of-Cycle DHA UBO Rates” after confirming current rates and files have been loadedNew: Contact external provider for pharmaceutical diagnosis code if payer requires and code does not flow from billing system
19Helpdesk (revised) Removed from the appendix and inserted in the guide Track x – xxx day –Removed from the appendix and inserted in the guideContact MTF, Region or Service Program Manager first, then DHA UBO, VPOC or MHS helpdesks as applicableDO not send PHI/PII“Review all s prior to sending them to the Helpdesks to ensure they do not contain PHI or PII. Remove and deidentify all unique person identifiers in your data before sending. Blocking or covering PHI or PII in a screen shot of encounter data is not sufficient.”DHA UBO and MHS training availablehttps://mhslearn.csd.disa.mil/ilearn/en/learner/mhs/portal/home.jsp
20Third Party Collection Program Report on Program Results (DD Form 2570 and UBO Metrics Report) (Revised)Track x – xxx day –Menu paths for DD 2570 data fieldsTPOCS menu path for outpatient billing and collection dataCHCS menu path for inpatient Non Active Duty (NAD) dataAdded menu paths for NAD outpatient visits data from the CHCS Workload Assignment Module (WAM) and the MHS Management and Analysis Reporting Tool (M2)Archived DHA UBO training webinar available on demand at
22Compliance (Revised)Track x – xxx day –Compliance plan and designation of compliance officer requiredMTF billing personnel must provide Compliance Officer with all requested information to complete Compliance Audit Checklists and worksheetsMinimum baseline examples of the items to be assessed are available atReview these documents to understand your program’s audit requirementsNew: “The MTF must correct any errors or deficiencies identified during the Compliance Audit.”
23Evaluation and Management (Revised) Track x – xxx day –Emergency Department E&M CPT® codes – 99285Current version: charges based on institutional APC rate; bill using UB-04/837IAfter transition to future billing system, ABACUS: charges based on TRICARE CMAC rates; bill using CMS 1500/837PRevised version adds:DHA UBO rates for inpatient (CPT® ) and outpatient consultation codes (CPT® ) are set to zero ($0.00). Thus, do not bill, and consult with coding personnel for review and correction.
24Medical Affirmative Claims (Revised) Track x – xxx day –Prior 8 Mar 2006 version incomplete: “MAC bills are itemized for outpatient care, and generated using the adjusted standardized amount multiplied by the relative weighted product for inpatient bills.”Revised version adds:Work with Patient Administration personnel and Recovery Judge Advocate (RJA) in addition to providers and coders to identify MAC cases following procedure in ManualWork with RJA to provide support for claimsUse DHA UBO inpatient, outpatient, and pharmacy rates once approved by the Office of Management and Budget (OMB)
25SIT/OHI (Revised) (Formerly Health Insurance) Track x – xxx day –MTFs should collect OHI with DD Form 2569 annually and verify/update with the beneficiary at every visitMaintain subscription to DEERS for most up-to-date OHI informationReview for current OHI before updating/enteringDo not enter placeholder informationNew: “Report any OHI MTF previously entered that has been changed or incorrectly entered to Include all data elements in question.”
26SIT/OHI (Revised) (Formerly Health Insurance) New: Common issues with OHI data quality include:Incorrect OHI reactivation, which causes un-billable encounters to feed to billing systemIncorrect OHI termination, which prevents billable encounters from feeding to the billing systemIncorrect OHI rank assignment, which causes initial billing to incorrect payerEntry of Placeholder Coverage ID / Placeholder HIC ID, which causes un-billable encounters to clog the billing systemMisclassification of non-commercial payers. For example, inclusion of non-commercial payers and healthcare coverage in the TPCP SIT and OHI databases, which causes non-billable/non-TPCP OHI (e.g., Medicare, Medicaid, Medicare Advantage, Medicare Part D) encounters to feed to the billing systemPotentially billing non-billable payers
27US Family Health Plan (revised) Track x – xxx day –Members agree to use 1 of 6 organizations that sponsor the USFHP, in different regions, throughout the United StatesNew: Members may not use MTFs unless:EmergencyUSFHP members should contact USFHP within 24 hours or the next business day for authorization. MTF should do so as well as soon as it learns about the encounter.Providers’ names and toll free 800 contact numbers are available atReferralRequires MOU between MTF and USFHP (none currently in effect)If an exception applies, the USFHP member should be registered under PATCAT K92B; bill the USFHP provider where the patient is enrolled.If no exception, the USFHP member should be registered as PATCAT K92A; bill patient/member directly.
28AppendicesUpdated to follow current information in DHA UBO training modules and to delete redundanciesB: UB-04C: CMS-1500D: UCFE: DD7A instructionsF: DD7 InstructionsG: Invoice and ReceiptsInstructions for completing the institutional and professional claim formats are available in online training modules and reference guide, “Data and Billing in Sync: UB-04/837i” and “CMS 1500/837P,” both available on the DHA UBO Learning Center at
29Wrap-Up After transition to future billing system, ABACUS: Do not use 99199; use APC and ASC for institutional chargesSubmit both 837I and 837P claims for inpatient institutional and inpatient professional including ED E&M servicesContinue to charge FMR, unless family member of AD TRICARE Prime member or if OHI billedUse TRICARE provider categories and appropriate rates for professional services chargesContinue to ensure system administrator has received and downloaded the most current version of rate files and tablesContinue to maintain current DEERS subscription; and verify OHIContinue to report any changed, modified, or incorrect OHI, previously entered, toContinue to use menu paths available for inpatient professional services and DD 2570 data fields
30Wrap-Up, cont. After transition to future billing system, ABACUS Continue not to bill if rate is $0.00, unless DHA UBO Program Office approves a rate requestProspective payments to USCG continue; bill only OHI and patients directly for elective cosmetic surgery and newborns of former USCG members or sponsor’s daughtersContinue to use DHA UBO VA-DOD Resource Sharing: Inpatient Institutional Calculator, Outpatient Billing Guide, and PPEContinue to correct any errors or deficiencies identified during the Compliance AuditContinue to work with coding personnel for review and correction of inpatient and outpatient consultation codesContinue to work with RJA to provide support for MAC claims and use OMB approved ratesContinue to notify USFHP POC as soon as billing office learns of USFHP emergency encounter
32Instructions for CEU Credit This in-service webinar has been approved by the American Academy of Professional Coders (AAPC) for 1.0 Continuing Education Unit (CEU) credit for DoD personnel (.mil address required). 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.Live broadcast webinar (Post-Test not required)Login prior to the broadcast with your: 1) full name; 2) Service affiliation; and 3) addressView the entire broadcastAfter completion of both of the live broadcasts and after attendance records have been verified, a Certificate of Approval including an AAPC Index Number will be sent via to participants who logged in or ed as required. This may take several business days.Archived webinar (Post-Test required)View the entire archived webinar (free and available on demand atComplete a post-test available within the archived webinaranswers toIf you receive a passing score of at least 70%, we will MHS personnel with a .mil address a Certificate of Approval including an AAPC Index NumberThe original Certificate of Approval may not be altered except to add the participant’s name and webinar date or the date the archived Webinar was viewed. 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 AAPCFor additional information or questions regarding AAPC CEUs, please contact the AAPC.Other organizations, such as American Health Information Management Association (AHIMA), American College of Healthcare Executives (ACHE), and American Association of Healthcare Administrative Managers (AAHAM), may also grant credit for DHA UBO Webinars. Check with the organization directly for qualification and reporting guidance.