1. CY12 Cosmetic Surgery Rates and CSE v8 Update Presented by TMA UBO Program Office Support From your computer or Web-enabled mobile device log into: http://altarum.adobeconnect.com/ubo. Enter as a guest, then enter your name plus your Service affiliation (e.g., Army, Navy, Air Force) for your Service to receive credit. http://altarum.adobeconnect.com/ubo 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-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 WEBMEETING@ALTARUM.ORG 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 “Send.”WEBMEETING@ALTARUM.ORG 26 June 2012 0800 – 0900 ET 28 June 2012 1400 – 1500 ET

2.  Background  Cosmetic Surgery Patient Information Brochure  CSE v8 New Procedures & Rate Methodology  CSE v8 Layout & Functional Changes  CSE Demonstration: Practice Scenarios  CSE v8 User’s Guide Update  CSE v8 Distribution & Effective Date  Questions & Answers 2 Agenda

3.  Elective cosmetic surgery is not a TRICARE covered benefit.  However, DoD Health Affairs Policy 05-020 authorizes elective cosmetic surgery in military treatment facilities (MTFs) to “support graduate medical education, board eligibility and certification, and skill maintenance for certified specialists.”  Services are provided on a “space available” basis and limited to: -TRICARE-eligible beneficiaries (including TRICARE for Life) who will not lose eligibility for at least 6 months. -Active duty personnel who have written permission from their unit commander.  All patients are fully responsible for surgical fees, applicable institutional and anesthesia charges, as well as the cost of all implants, cosmetic injectables, and other separately billable items associated with elective cosmetic procedures. 3 Background

4. 4 The Basic Process Patient Presents for Surgery Consult Provider Examines Patient Provider Determines Procedure is Elective Cosmetic Surgery Provider Completes CSE Superbill Patient Takes CSE Superbill to MSA Clerk MSA Clerk Enters Information into CSE MSA Clerk Prints CSE Report and Gives to Patient

5. 1)Advance Payment Required Estimated charges must be paid, in full, prior to receiving treatment. 2)Prices Subject to Change Rates are not guaranteed until estimated charges have been paid in full. 3)Additional Charges May Apply There may be additional charges for services such as laboratory, radiology, and pharmacy, or unforeseen, but necessary, procedures undertaken during the procedure. 4)Global Periods Postoperative visits that are unrelated to the original procedure, or that occur after the global period has expired, will incur additional charges. 5)Refunds Refunds are processed for procedures not performed. 6)Follow-up Care Follow-up care is not guaranteed in an MTF and in accordance with TPM Chapter 4, Section 1.1, complications of cosmetic surgery procedures are excluded from coverage. 5 Acknowledgement of Terms

6.  Target Audience: -Patients considering elective cosmetic surgery -Patients receiving a cosmetic surgery estimate  Topics Covered: -Eligibility -Payment -Standard Process:  Consultation  Estimate & Payment  Scheduling  Post Procedure 6 Elective Cosmetic Surgery Brochure

7. Substitute Skin Grafts 15271 Application of skin substitute graft to trunk, arms, first 25 sq cm +15272 Application of skin substitute graft to trunk, arms, add’l 25 sq cm 15273 Application of skin substitute graft to trunk, arms, legs, > 100 sq cm +15274 Application of skin substitute graft to trunk, arms, legs, add’l 100 sq cm 15275 Application of skin substitute graft to face, scalp, eyelids, mouth… first 25 sq cm +15276 Application of skin substitute graft to face, scalp, eyelids, mouth… add’l 25 sq cm 15277 Application of skin substitute graft to face, scalp, eyelids, mouth… > 100 sq cm +15278 Application of skin substitute graft to face, scalp, eyelids, mouth…add’l 100 sq cm Biologic Implant +15777* Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement *CPT ® code 15777 can be used with any of the above procedures as well as the following procedures currently listed in the CSE: 7 New Cosmetic Procedures for 2012 19340 Immediate insertion of implant 19342 Delayed insertion of implant 19357 Breast reconstr; immed. / delayed 19370 Open periprosthetic capsulotomy 19371 Periprosthetic capsulectomy; breast 19380 Revision of reconstructed breast 19300 Mastectomy for Gynecomastia 19316 Mastopexy (Breast Lift) 19318 Mammaplasty; reduction 19324 Mammaplasty; augmentation w/o implant 19325 Mammaplasty; augmentation w/ implant 19328 Removal of intact mammary implant 19330 Removal of implant material (+) Indicates an Add-on Code

8. 0 Days 17999-Y0019 Laser hair removal; chest 17999-Y0020 Laser hair removal; lip 17999-Y0021 Laser hair removal; lip and chin 17999-Y0022 Laser hair removal; back 17999-Y0023 Laser hair removal; arms 17999-Y0024 Laser hair removal; underarms 17999-Y0025 Laser hair removal; bikini 17999-Y0026 Laser hair removal; legs 17999-Y0027 Laser hair removal; beard 17999-Y0028 Laser hair removal; ears 17999-Y5000 Microlipoinjection/fat transfer; lips 17999-Y5001 Microlipoinjection/fat transfer; melolabial folds 17999-Y5002 Microlipoinjection/fat transfer; marrionette lines 17999-Y5003 Microlipoinjection/fat transfer; forehead 17999-Y5004 Microlipoinjection/fat transfer; glabella 17999-Y5005 Microlipoinjection/fat transfer; tear troughs 17999-Y5006 Microlipoinjection/fat transfer; crows feet 17999-Y5775 Micro/mini grafts 1- 500 hairs 17999-Y6001 Each Piercing, Each Body Location 8 Global Periods for Y codes 10 Days 17999-Y0050 Laser Vein Treatment of Leg 30 Days 17999-Y0030 Laser tattoo removal; <= 30 sq. cm, initial session 17999-Y0031 Laser tattoo removal; <= 30 sq. cm, each addl session 17999-Y0032 Laser tattoo removal; >= 31 sq cm, initial session 17999-Y0033 Laser tattoo removal; >= 31 sq cm, each addl session * Based on the unique nature of the procedure requiring multiple sessions at specified intervals 90 Days 17999-Y0001 Microdermabrasion; total face 17999-Y0002 Microdermabrasion; segment, facial 17999-Y0003 Laser Skin Resurfacing, Ablative; total face 17999-Y0004 Laser Skin Resurfacing, Ablative; segment, facial 17999-Y0005 Laser Skin Resurfacing, Non-ablative; total face 17999-Y0006 Laser Skin Resurfacing, Non-ablative; segment, facial 17999-Y0007 Laser Skin Resurfacing, Non-ablative; neck 17999-Y0008 Laser Skin Resurfacing, Non-ablative; chest 17999-Y0009 Laser Skin Resurfacing, Non-ablative; back and shoulder 17999-Y0010 Laser Skin Resurfacing, Non-ablative; arms 17999-Y0011 Laser Skin Resurfacing, Non-ablative; hands 17999-Y0012 Laser Skin Resurfacing, Non-ablative; legs 17999-Y5831 Abdominoplasty 17999-Y5835 Buttock Augmentation w/ implant 17999-Y5836 Buttock Augmentation w/o implant 17999-Y5837 Calf Augmentation 17999-Y5838 Umbilicoplasty Global periods for Y codes are based on CMS global periods for comparable procedures with current valid CPT ® codes.

9. 9 Updated Superbill INSTRUCTIONS: Circle/highlight Procedure Description; check Bilateral (Bi) column; and enter the Quantity (Qty) of each procedure.

10. Professional Fees + Facility Fees + Anesthesia Fees + Cost of Implants & Pharmaceuticals (e.g., Breast Implants, Chin Implants, Botox ®, Restylane ® ) =TOTAL COST 10 Cost of Elective Cosmetic Procedures

11.  Current Methodology: Anesthesia fees apply only to the primary procedure.  New Methodology: Anesthesia fees will be applied to both the primary procedure as well as additional procedures when General/Monitored Anesthesia Care is selected.  Rationale: This methodology accounts for the additional anesthesia drug and additional anesthesiology services provided to the patient when multiple procedures are performed. 11 New Rate Methodology-Anesthesia General/Monitored Anesthesia Care (Anesthesia Base Units (Primary Procedure) + Average Time (Primary Procedure) + Average Time (Procedure 2) + … x TRICARE Anesthesia Conversion Factor

12.  Current Methodology: The facility fee for add-on codes performed in an outpatient operating room are reduced by 50%.  New Methodology: Eliminates multiple procedure discounts for add-on codes.  Rationale: Rates assigned to add-on codes are inherently “additional procedure rates” due to the nature of the procedure itself always being secondary to another procedure. Add-on codes are not subject to multiple procedure discounting. 12 New Rate Methodology—Add On Codes All Add-On Codes Professional Fee, 100% Facility Fee, 100% No additional Anesthesia Fee

13.  Current Methodology: No facility fee is charged for additional inpatient procedures.  New Methodology: A reduced facility fee will be included for multiple inpatient procedures.  Rationale: The new calculation maintains consistency with the current CSE outpatient rate methodology. 13 Rate Methodology—Inpatient Procedures CSE v7 (July 2011) Primary Inpatient Procedure: Professional Fee, 100% Facility Fee, 100% Anesthesia, 100% Additional Inpatient Procedure: Professional Fee, 50% No Additional Facility Fee No Additional Anesthesia Fee CSE v8 (July 2012) Primary Inpatient Procedure: Professional Fee, 100% Facility Fee, 100% No Additional Anesthesia Fee Additional Inpatient Procedure: Professional Fee, 50% Facility Fee, 50% No Additional Anesthesia Fee

14. 14 CSE v7-Primary Procedure Screen

15. 15 CSE v8-Primary Procedure Screen Section 2: Costs are automatically calculated Section 3: Edit Estimate Entries View, Print, Save a Cost Report Section 1: Enter a Primary Procedure

16. 16 CSEv7-Additional Procedure Screen

17. 17 CSEv8-Additional Procedure Screen Section 1: Additional Procedure Entry Form Section 2: List of Additional Procedures Added to the Estimate

18. 18 CSE-Cost Report

19. 19 Saving A Cost Estimate

20.  Issue: Estimates can only be generated for initial and additional sessions together. Often times, additional sessions are scheduled after the initial session has been performed.  Solution: Procedure codes representing “additional sessions” are available in the CSE as either a primary or additional procedure. Example: 20 Pricing an Additional Session Only Procedure Code Description 17999-Y0031Laser tattoo removal; <= 30 sq cm, each add’l session 17999-Y0033Laser tattoo removal; >= 31 sq cm, each add’l session

21.  Issue: Estimates cannot be generated for: -Pharmaceuticals for patients who have chemodenervation touch-ups within the global period -Cosmetic implants priced after the initial estimate has been generated -Elective implants for medically necessary procedures  Solution: New codes have been created that will allow estimates for pharmaceuticals, implants, and supplies without an associated procedure. 21 Pricing Only a Pharmaceutical Procedure CodeDescription J9999Pharmaceutical Only C9999Implant or Supply Only

22. CSE v8 Demonstration: Practice Scenarios 22

23.  A patient returns 6 days after having the following procedure: -CPT ® code -64612 Chemodenervation of muscle(s) innervated by facial nerve -This procedure has a 10 day global period 23 Practice Scenario #1: Pharmaceutical Only PHARMACEUTICAL ONLYPriceQty Name:J9999 IMPLANT/SUPPLY ONLYPriceQty Name:C9999 Xeomin ® $8.99 5

24. CSE Demonstration #1: Pharmaceutical Only 24

25.  A patient is scheduled to have a melanoma lesion removed and requests that a skin graft to remove an unsightly birthmark be performed at the same time. The birthmark is approximately 50 sq cm in size and the graft will require a biologic implant to close the wound.  The procedure will be performed: 1)In an OR/outpatient setting 2)With general anesthesia. 25 Practice Scenario #2: Multiple Add-on Codes Description CodeBilateral?Quantity SKIN SUBSTITUTE GRAFT Trunk, arms, legs Wound area ≤ 100 sq cm; first 25 sq cm15271 Wound area ≤ 100 sq cm; ea add'l 25 sq cm 15272 + Wound area ≥ 100 sq cm; first 100 sq cm15273 Wound area ≥ 100 sq cm; ea add'l 100 sq cm 15274 + BIOLOGIC IMPLANT (May be used w/ any of the above skin graft procedures) Implantation of biologic implant 15777 + 1 1

26. CSE Demonstration #2: Multiple Add-on Codes 26

27. CHEMODENERVATION (Procedure performed by resident? Yes No ) Description CodeBilateral?Quantity Chemodenervation; facial 64612 QtyPrice Botox ® J0585 $5.36 Chemodenervation; eccrine glands, both axillae 64650 QtyPrice Botox ® J0585 $5.36 27  A patient requests Botox ® injections for unsightly crows feet and embarrassingly sweaty palms.  The procedure will be performed: 1)In a provider’s office by a dermatology resident 2)With topical anesthesia. Practice Scenario #3: Chemodenervation 25 10

28. CSE Demonstration #3: Chemodenervation 28

29.  Redesigned to work as a ‘Help’ function in the Estimator.  Press F1 to open a new window displaying the CSE User’s Guide.  Hyperlinks allow users to easily navigate to different sections of the document.  Provides line by line instructions and information.  Incorporates all of the tables from the previous version. 29 User’s Guide Update

30. CSE Demonstration: Electronic User’s Guide 30

31.  The CSE v8 application and all associated materials will be available for download from the new Cosmetic Surgery Estimator Web site at: https://www.ubocse.org.  Files will be password protected for controlled access.  User ID and password will be distributed to UBO Service Managers who will disseminate information to MTF staff. 31 CSE v8 Distribution

32.  Cosmetic Surgery Rates are included in the CY 2012 Outpatient Itemized Billing (OIB) Rate Package which is scheduled to be effective 1 July 2012. 32 Effective Date

33. 33 Questions & Answers

34.  Please contact the UBO Helpdesk if you have any questions or concerns at (703) 575-5385 or UBO.helpdesk@altarum.org. 34 Contact Us

35.  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. UBO.LearningCenter@altarum.org  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. ubohelpdesk@altarum.org 35 Instructions for CEU Credit

36.  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. 36 Instructions for CEU Credit, cont.

37.  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. 37 Other Organizations Accepting AAPC CEUs