CY2014 Outpatient Rates Update Presented by Tiffani B-C. Brooks, MPA, MGH, DHA UBO Program Office Contract Support From your computer or Web-enabled mobile device log into: Enter as a guest, then enter your name plus your Service or NCR MD affiliation (e.g., Army, Navy, Air Force) for your Service or NCR MD to receive credit. Instructions for CEU credit are at the end of this presentation. [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.] Listen to the Webinar by audio stream through your computer or Web-enabled mobile 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 so 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 10 June EDT 12 June EDT

 CY2014 Outpatient Rates Deployment Overview -Rates Packages -CY2014 Effective Dates  Legacy Systems (CHCS/TPOCS) Update -Mapping Table Updates -Service Rate Requests  New Solutions (Central Billing Events Repository (CBER)/Armed Forces Billing and Collection Utilization Solution (ABACUS)) Update AGENDA 2

 Rates Packages: -CY2014 Outpatient Rates were developed for dual billing systems/solutions  Legacy solutions including CHCS/TPOCS, other systems currently in use, and ABACUS with data directly from CHCS  CBER/ABACUS  CY2014 Effective Dates: -Legacy Rate Package effective 1 July New Solutions Rate Package effective upon implementation and availability of CBER/ABACUS billing capabilities -MAC billing effective on approved date by OMB AND published in the Federal Register CY2014 OUTPATIENT RATES DEPLOYMENT OVERVIEW 3

LEGACY SYSTEMS UPDATE CHCS AND TPOCS 4

 Outpatient rates are developed by the DHA UBO for each outpatient encounter, service, procedure, or supply provided at an MTF.  UBO CHAMPUS Maximum Allowable Charge (CMAC) rates are developed for reimbursement in the purchased care community.  Medical Expense Program Reporting System (MEPRS) data is used to calculate the average MTF operational expenses. LEGACY SYSTEMS UPDATE: Outpatient Rates Overview 5

 The CMAC and CMAC Component rate files are the primary outpatient rate tables and are categorized by CMAC localities.  Within the DHA UBO, certain CMAC codes are not available for separate reimbursement and are either set to $0.00 or require specialty handling with reasonable rate applied.  The 2014 Overall Percent Change: 1.59%. LEGACY SYSTEMS UPDATE: CMAC Rates Overview 6

 Evaluation & Management Codes ( ) -Used for Hospital level (1-5) ED encounter -Only represents the institutional portion -Mapped to the UB 04/837I LEGACY SYSTEMS UPDATE: CMAC Emergency Department (ED) Rates 7

ANESTHESIA:  TRICARE Anesthesia Reimbursement Formula -(Time Units + Base Units) X National Average Conversion Factor DME/DMS:  Expenses allocated for equipment and supplies -Used the ‘floor rate’ of the 2014 CMS DMEPOS fee schedule -DME rates are dependent on both the HCPCS code and the modifier (e.g., new, used, rented) -Used purchased care data to develop rates for existing DME/DMS procedures not included in existing CMS table LEGACY SYSTEMS UPDATE: Anesthesia & DME/DMS 8

LEGACY SYSTEMS UPDATE: Observation Rates  Ambulatory services performed within the hospital’s ED or nursing unit −Captures both institutional and professional components −Captures the number of hours a patient is in Observation −TRICARE APC Payment based off of a stay >/= 8 hours a patient is in the OBS unit 2014 RatePer Day Charge 99218$ $ $ $ $ $ G0378$86.13 G0379$ Direct Admit 9

 Methodology for Applying Immunization Rates MEPRS Based Flat Rate = $51.00 CMAC – TRICARE provided rate Purchased Care Allowable Amount National Average Payment Rate MEPRS Based Flat Rate LEGACY SYSTEMS UPDATE: Immunization Rates 10

LEGACY SYSTEMS UPDATE: MEPRS Based Rates MEPRS Based Rates 11

Computation and Burdening Factors Asset Use GSUR Costs Military Pay Civilian Pay ‘DMDC’ Factor DHP Growth LEGACY SYSTEMS UPDATE: MEPRS Based Rates Recoup depreciation & interest costs Military medical personnel salary expenses Percentage growth in budget Retirement, health benefits and life insurance Pay raise percentage - presidential budget 12

LEGACY SYSTEMS UPDATE: MEPRS Based Rates 13

DMIS ID Mapping Table  The Defense Medical Information System Identifier (DMIS ID) Mapping Table is used as a way of controlling both medical and military facility identification and cost/workload classification. Revenue Mapping Table  Identifies the CPT®/HCPCS procedure, supply, drug code, description and available revenue centers. -Revenue center code informs the payer where the procedure was performed -Used default 510 (clinic) revenue code where no revenue center was indicated LEGACY SYSTEM UPDATES: Mapping Tables 14

TPOCS Mapping Table  Table contains specific code ranges that maps to various applicable modifiers, claim forms and indicates which rate table to find the charge -Specifically designed for the TPOCS billing environment -CPT®/HCPCS driven Modifier Mapping Table  Contains a list of modifiers that can be attached to specific ranges of codes and which rate table to find the charge -Modifier driven – to identify applicable code ranges -Released January 2014, No July update LEGACY SYSTEM UPDATES: Mapping Tables 15

Service Rate Requests OTHER OUTPATIENT ITEMS 16

OTHER OUTPATIENT ITEMS: Service Rate Requests CPT®/HCPCS CODE Type of CodeRate TableMethodology A6025 A6533 L3290 L3649 DME_DMSDMEPurchase Care Data – allowable amounts Unlisted ProceduresCMAC Purchase Care Data – allowable amounts with a weighted average 90661Immunization/InjectableImmunizationTRICARE provided rate C1788 H0004 – H0031 Q4008 – Q4049 VariousCMAC Purchase Care Data – allowable amounts 17

OTHER OUTPATIENT ITEMS: Service Rate Requests CPT®/HCPCS CODE Type of CodeRate TableMethodology VariousCMACAPC 99071Educational Supplies __Not billable; No rate assigned J3490Unclassified Drug__ Not billable; No rate assigned T1007Substance abuse treatment plan__ Not billable; No rate assigned T1016 G9001-G9012 Case Management__Not billable; No rate assigned 18

CBER AND ABACUS NEW SOLUTIONS UPDATE 19

 Central Billing Events Repository (CBER) -CBER is an extension of the MHS Data Repository (MDR) -Uses MDR (e.g., CHCS, DEERS, MEPRS) source inputs for institutional (837I), professional (837P) and pharmacy (NCPDP D.0) billing transactions -Provides reference files for billing -Will not create actual claims or provide encounter documentation  Armed Forces Billing and Collection Utilization Solution (ABACUS) -All Services and NCR MD will use ABACUS -Receives CBER encounter extract files and reference files -Implements DHA UBO rates and business rules -Generates 837I, 837P and NCPDP D.0 claims as well as required paper claims for all 3 MHS cost recovery programs MSA, TPCP and MAC NEW SOLUTIONS UPDATE: CBER/ABACUS Capabilities 20

 Impact on Outpatient Rates -Continue to be based on what TRICARE allows -MAC billing will continue to require OMB approval and publishing in the Federal Register  Changes to Look For as Operations Migrate to the CBER/ABACUS Solution -DHA UBO CMAC Format Change -CHCS Provider Classes to TRICARE Provider Categories -Use of Ambulatory Payment Classification (APC) and Ambulatory Surgery Center (ASC) charges to recover institutional charges -Anesthesia professional services -ED services NEW SOLUTIONS UPDATE: CBER/ABACUS 21

Ambulatory Payment Classification (APC) charges used to recover institutional hospital outpatient charges at bedded facilities  Adjusted for geographic wage variation based on the labor-related portion of the service  Assigned to a Status Indicator (SI) that provides additional business rules for billing. Ambulatory Surgery Center (ASC) charges are used to recover the institutional cost for surgery procedures performed in freestanding ASCs (non-bedded surgical facilities)  Payment rates only apply to facility charges for ambulatory surgery. -A standard overhead amount that includes nursing and technician services NEW SOLUTIONS UPDATE: APC and ASC CHARGES 22

NEW SOLUTIONS UPDATE: Using APC and ASC  For APV procedures and services: How to use 99199? -WITH CBER/ABACUS (after implementation)  For procedures with dates of service (DOS) on or after the MTF transition date: MTFs should recover facility institutional costs through APC and ASC charges AND NOT BILL Prior to CBER/ABACUS  Billing through legacy systems is appropriate for DOS before the transition to the CBER/ABACUS solution 23

NEW SOLUTIONS UPDATE: TRICARE Professional Services TRICARE Provider CategoriesTRICARE CMAC Payment Structure Category 1 - Services of MDs, DOs, optometrists, podiatrists, psychologists, oral surgeons, audiologists, and certified nurse midwives (CNMs); In a facility including hospitals (both inpatient and outpatient care), ambulances or ASCs Category 2 - Services of MDs, DOs, optometrists, podiatrists, psychologists, oral surgeons, audiologists, and CNMs; In a non- facility including provider offices and other non- facility settings Non-facility CMAC rate applies to OT, ST and PT regardless of the setting Category 3 - Services, of all other providers not found in Category 1; In a facility Category 4 - Services, of all other providers not found in Category 2, In a non-facility Non facility CMAC for physician class Facility CMAC for physician class Non facility CMAC for non- physician class Facility CMAC for non-physician class Physician class Professional Component (PC) rate Physician class Technical Component (TC) rate Non physician class PC rate Non physician class TC rate 24

NEW SOLUTIONS UPDATE: TRICARE Professional Services -- REFERENCE When to Use  Category 1 - Services provided by physicians, and those included under the term "physician"  Physician Facility; Care in a facility that generates a separate bill (e.g., hospital, ambulatory surgery center, ED)  Category 2 - Services provided by physicians, and those included under the term "physician"  Physician Non-facility; Care that covers both the professional and institutional component (e.g., clinic)  Physical Therapists, Occupational Therapists and Speech Pathologists are included as “physicians”; ALWAYS billed using Category 2: Physician Non-facility  Claim is for both professional and institutional components (e.g., doctor's office)  Category 3 - Services provided by non-physicians, and not included under the term "physician"  Non-physician Facility; Institutional charge billed on a separate claim  Claims generated at an amount lower than "physician  Category 4 - Services provided by non-physicians, and not included under the term "physician"  Non-physician Non-facility; Claim includes both professional and institutional charges 25

ED Codes  With CBER/ABACUS, submit both institutional and professional claims -For professional services/charges, use TRICARE provided rates (CMAC - facility physician rate)  837P Professional Claim Form -For institutional services/charges, use APC rates  837I Institutional Claim Form NEW SOLUTIONS UPDATE: Emergency Department Services 26

 Anesthesia professional charges are applied in both inpatient and outpatient settings.  Charges based on the procedure performed, base units for procedure, minutes of service and provider conversion factor -Minutes of service are converted to units of service and rounded up  15 minutes = 1 unit  16 minutes = 2 units  Anesthesia Charges = Total Units x locality adjusted conversion factor -Total Units = Procedure Base Units + Actual Encounter Time Units NEW SOLUTIONS UPDATE: Anesthesia Services 27

NEW SOLUTIONS UPDATE: Major Outpatient Rates Changes with CBER/ABACUS CHCS/TPOCS: Legacy Systems CBER/ABACUS: New Solutions APC and ASC useAPC rates used to set UBO CMAC professional rates for certain codes Both APCs and ASCs rates used to recover institutional cost for outpatient ambulatory procedures Use of 99199APV - Flat institutional rate for all APV services and procedures Recover facility institutional costs using APCs and ASCs, DO NOT BILL

NEW SOLUTIONS UPDATE: Major Outpatient Rates Changes with CBER/ABACUS CHCS/TPOCS: Legacy Systems CBER/ABACUS: New Solutions Professional Services RatesCHCS Provider Classes based on HIPAA taxonomy TRICARE Provider Categories based on HIPAA taxonomy ED Services ( )ED rates mapped to APC rates and represent institutional component of ED visit; submit on institutional claim and cannot bill professional component due to system limitations Both professional and institutional components of ED procedures can be submitted on institutional (APC rates) and professional(CMAC rates) claims 29

NEW SOLUTIONS UPDATE: Major Outpatient Rates Changes with CBER/ABACUS CHCS/TPOCS: Legacy Systems CBER/ABACUS: New Solutions AnesthesiaTRICARE Anesthesia Reimbursement Formula (Avg. Time Units + Base Units) X National Average Conversion Factor Flat rate per procedure (Base Units + Actual Encounter Time) X locality adjusted conversion factor Locality driven System FormattingTables Modified for Legacy Systems following TRICARE with exceptions for MHS system limitations Tables Modified for CBER/ABACUS following TRICARE Formats 30

Legacy UBO CMAC-Based Rate File Legacy UBO CMAC-Based Component Rate File NEW SOLUTIONS UPDATE: UBO CMAC Format Legacy Solutions 31

CBER/ABACUS UBO CMAC-Based Rate File NEW SOLUTIONS UPDATE: UBO CMAC Format CBER/ABACUS Solution 32

 Legacy Systems.... -Rates effective for services performed on or after 1 July Outpatient rates are developed by the DHA UBO for each outpatient encounter, service, procedure, or supply provided at an MTF.  CMAC; Immunization/Injectible; DME/DMS; Anesthesia; MEPRS Based Rates (Ambulance, APV, Dental, specific Immunization, Gov’t discounts)  MAC billing (current and after transition to CBER/ABACUS)... -Rates used will be the same as those included in the IP, OP and Rx rate packages; however, inpatient and outpatient will continue to be approved by the OMB and published in the Federal Register before they can be used for MAC purposes 2014 Outpatient Rates: Summary 33

 CBER/ABACUS -Rates effective upon implementation and availability of billing capabilities -Upon implementation - ability to bill for both professional and institutional services  Billing will follow more closely to TRICARE reimbursement practices as well as commercial billing practices -Outpatient Rate Changes  DHA UBO System Format Change; Use of APC and ASC charges; Discontinued billing of ‘99199’; Transition from CHCS Provider Classes to TRICARE Provider Categories; Anesthesia services calculated based on locality, provider type, actual encounter time and units of service; and Ability to bill both professional and institutional components for ED services 2014 Outpatient Rates: Summary Con’t. 34

QUESTIONS? 35