Presentation on theme: "A condition is only service connected if it has been rated as an adjudicated service connected disability through the Veterans Benefits Administration."— Presentation transcript:
1 The Clinician’s Guide to Answering the Service-Connected Classification Question
2 A condition is only service connected if it has been rated as an adjudicated service connected disability through the Veterans Benefits Administration (VBA).A condition is only service-connected if it has been rated service-connectedthrough the Veterans Benefits Administration
3 OBJECTIVESThis presentation will provide staff with information that will aid in correctly designating a visit as service connected (SC) or non service connected (NSC).
4 The encounter form or computer screen will display: Visit Related To:Service Connected ConditionCombat Vet (Combat Related)Agent Orange ExposureIonizing Radiation ExposureEnvironmental ContaminantsMSTHead and/or Neck CancerYes NoA veteran may have multiple encounters per visit. For the service-connected veteran, each and every encounter must have the service-connected classification question answered: Is treatment related tothe service-connected condition? This question should be answeredusing all available information related to the service-connectedcondition and the treatment provided.Is treatment for a service connected condition?It is the responsibility of the provider to mark the encounter based on their clinical judgment and eligibility information as: * service connected or *non service connected
5 Why the SC/NSC determination is so important? Monitored by:CongressOffice of Management and Budget (OMB)Top VHA OfficialsThird Party PayersVeterans (patients)VHA requires this data for:Utilization studiesResearchBudgetingBusiness Office operationsWhy is the SC/NSC determination so important? VHA uses thisstatistical information in reports to Congress, OMB and internalindividuals and groups. This data is taken into consideration inutilization studies, budget planning and research. Because VAcan only send insurance claims for the treatment ofnonservice-connected conditions it is imperative that we havean accurate determination that can only be made by a clinician.
6 BILLING REQUIREMENTTitle 38 legislation requires VHA to bill for care provided for a condition that is not service connected or a special authority.Bills are processed for non service connected care, which includes adjunct and secondary conditions.
7 What is a service-connected condition? “Service-connected” refers to a VBA decision that a veteran’s illness or injury was incurred in or aggravated by military service.VBA establishes the degree of disability for each service connected condition.A veteran may have more than one adjudicated service connected condition.If the primary rated condition worsens over time, encourage patient to have VBA complete a reassessment of rated disabilities.What is a service-connected condition? Service-connected” refersto a VA decision that a veteran’s illness or injury was incurred in oraggravated by military service. This decision is made by the VARegional Office by reviewing specific clinical documentationpertaining to the veteran’s claimed condition. The adjudication ofthe claim, the percentages of disability assigned and thecompensation awarded are made according to a rating scheduleestablished by law. A veteran may have more than oneservice-connected condition.
8 What does the SC % rating represent? The percentage ratings represent as far as can practically be determinedThe average impairment in earning capacity resulting from such diseases andInjuries and/or their residual conditions in civil occupations.
9 Other Encounter Classifications If applicable the provider should also indicate if the encounter is for care due to (special authorities):Agent Orange exposureIonizing Radiation exposureEnvironmental ContaminantsMilitary Sexual TraumaHead and/or Neck CancerCombat ServiceSHAD (Shipboard Hazard and Defense)
10 Service-Connected billing Treatment provided for service connected conditions or special authorities is not billableExceptionWorkers compensation or tort feasor claims for injury of service-connected disability (Notify your facility revenue office when you encounter a patient with a work related injury/condition.)Reference: M-1, Part I Chapter 15, section b (5). VA can bill: "Veterans for service-connected disabilities when it is medically determined that re-injury or aggravation of the service-connected disability is due to a compensable occupational injury or disease or the negligence or other legal wrong of a third person.”
11 IMPORTANT“Service connected” does not mean that all treatment a veteran receives is considered to be service connectedThe treating clinician is responsible for the determination based on accurate service connected information within the patient record, not just from what the patient states, for each patient encounter and/or medication prescription.Having a service-connected disability does not mean that all thetreatment you provide for that veteran should be determined to beservice-connected. Your responsibility is to determine if you aretreating a service-connected disability, document that treatment inthe record and make sure you have indicated your determinationabout the treatment in the record and on the encounter form.
12 Where to find information about the veteran’s service connection Electronic Encounter FormConsolidated Health RecordComputerized Patient Record SystemPatient InterviewAppointment ListPatient InquiryAppointment ManagementRating DecisionRegistration and eligibility staffThere are many areas within VISTA that show the veteran’sadjudicated disabilities. You should find them listed on the EncounterForm. They are also in the administrative record portion of theconsolidated health record. If you don’t have access tothis information and it is not provided for you, contact the eligibilitystaff or service line administrator at your facility.
13 VBA Rating Codes for Service connected Conditions Vague CodesWhat Do They Mean??Where do I find more information?The best source to clarify the patient’s rated condition is the individual rating decision for the patient.For general information about ratings, codes, and percentages visit the VBA website:
14 How to make a SC/NSC determination The clinician documents all identified conditions and treatment given during an encounter. (These may be different than what the veteran was scheduled).Mark the encounter form with the appropriate diagnostic and procedure codes. Remember: the clinical documentation MUST support your choices.When you are marking the diagnoses for the encounter, remember that you aredocumenting the diagnoses treated during that specific encounter notthe veteran’s active problems nor even perhaps, the reason for thescheduled appointment. For example, you are the veteran’s primarycare physician. You are scheduled to see the veteran today as afollow-up for his hypertension. However, when the veteran reportsfor his appointment, he is complaining of shortness of breath,congestion, cough, fever, etc. After your examination and a chestx-ray, you diagnose the veteran with pneumonia. Even though theveteran was scheduled to be seen for his hypertension, the pneumoniapresented a more immediate need for care. If you provided treatment only forhis pneumonia, then pneumonia is the only diagnosis you would list for thisencounter. You need to mark the encounter form correctly and make sure yourvisit documentation is consistent with your encounter form entries.
15 How to make a SC/NSC determination Determine if the condition for which the veteran is treated is specifically for any service connected condition(s)If it is, mark the encounter as service connected.If it is not, mark the encounter as Non service connected.Now you need to determine if the primary diagnosis is the serviceconnected condition. In the case we just looked at it is unlikelythe pneumonia would be service-connected. If it is notservice-connected you need to indicate that the visit was for an NSCcondition both in the record and on the encounter form.
16 MedicationsMedications for conditions adjunct/secondary (associated with) or aggravated by the service connected rated conditions are billable.This includes drugs that may prevent co-morbid disease progression and/or treat secondary or adjunct conditions.If the medication is for an adjunct/secondary condition, mark the prescription as Non service connected.If the medication is for an adjudicated service connected condition or special , mark the prescription as service connected.
17 Adjunct Conditions Remember If the treatment provided was for a condition which you consider to be adjunct/secondary (associated with) or aggravated by the service-connected condition(s), you MUST answer NO to the service connected classification question!Conditions that are considered adjunct or aggravated by the service-connected condition are NOT considered service-connected. Forexample, a veteran who is service-connected for diabetes may betreated for peripheral neuropathy. Peripheral neuropathy may beconsidered adjunct or aggravated by his service-connectedcondition. However, he is not service-connected for peripheralneuropathy, therefore, if this is the sole diagnosis for the encounter,you must answer NO to the service-connected classificationquestion.
18 Frequently Asked Questions Q. Do veterans receive free care at the VA Medical Center?A. Not all veterans.Most veterans have a Medication co-payCertain priority patients by law through income-based determinations (Means Test) must make co-payments
19 Frequently Asked Questions Q. If I don’t mark the encounter as service-connected, will the veteran be eligible for the service?A. Yes. Public Law , The Veterans Health Care Eligibility Reform Act of 1996, created a medical benefits package which is available to all enrolled veterans.
20 Frequently Asked Questions Q. If a patient is 100% service connected for a specific condition, are all their encounters service connected?A. No. The percentage (%) of service connection pertains only to the rated condition. If the encounter was for a non service connected condition, it would not be considered a service connected encounter.If a patient is 0% or 100%, they are still rated for that specific condition.
21 Frequently Asked Questions Q. Are encounters marked as AO, EC, MST, CV etc…(special authorities) billable?A. No* If check-out under special authorities, such as Title 38 USC 1710(e), the encounters do not trigger 1st party charges nor the Integrated Billing package.
22 Frequently Asked Questions Q. Must the veteran’s private insurance company be billed for conditions that are adjunct or secondary to the service-connected condition?A. Yes. Current interpretation of the law:Adjunct condition associated with or aggravating a disease or condition which is service connectedSecondary condition has been caused or is the result of a service connected conditionAdjunct and secondary conditions are not serviceconnected per interpretation of the law and should bebilled to the insurance carrier
23 Frequently Asked Questions If a veteran is treated for both a service connected and non service connected condition at the same visit, should the provider, mark the encounter as service-connected?A. Yes. If the primary diagnosis is service connected, the visit is marked service connected. If the primary diagnosis is not service connected and treatment was provided for a secondary diagnosis that is service connected (excluding mention of stable chronic conditions and routine medication refills), the visit is marked service connected.
24 Do You Have Other Questions about the SC/NSC Determination Process? Contact your local Revenue Office for assistance.