UBO USER GUIDE UPDATE Presented by DHA UBO Program Office Contract Support 29 April 2014 0800 – 0900 1 May 2014 1400 – 1500 For entry into the webinar,

UBO USER GUIDE UPDATE

Presented byDHA UBO Program Office Contract Support

29 April 2014 0800 – 09001 May 2014 1400 – 1500

For entry into the webinar, log into: http://altarum.adobeconnect.com/ubo.

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 at [email protected].

You 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.

Agenda

• Purpose of UBO User Guide

• Process and timelines

• Overview of Changes/Document Change History

• New layout and reorganization

• Key changes in policy, procedures, and processes

• Wrap-Up

• Questions

2

Purpose of UBO User Guide

• 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.”

3

Update Process

• DHA UBO Program Office prioritized sections P1-P4 with UBO Advisory Work

Group (AWG) review and opportunity to comment/input

• Delete in-depth coding discussions and other verbiage not directly linked to

billing and collections

• Delete outdated information and procedures

• Standardize 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

4

Update Process, cont.

• 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 applicable

– update all TPOCS references to “future billing system” as applicable

• References

– Direct quotes from original source documents and consistent verbiage between sections used when possible to prevent differences in interpretation

• Language of Responsibility – for both clarification of intent and consistency of use

– Shall

– May

– Will5

New Cover

6

Document Change History, Priority 1 Published 13 Dec 2013

• Added Sections

– Help Desk Support (formerly Appendix A – Helpdesk & Hotline

Support)

– Billing Inpatient Services

– Billing Outpatient Services

– U.S. Coast Guard Billing

– VA-DOD Resource Sharing

– Billing 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

7

Document Change History, Priority 1 Published 13 Dec 2013, cont.

• Revised Sections– Overview– Helpful Links– Ambulatory Procedure Visits– DD7/DD7A Reports Process– Emergency Department Services– File and Table Maintenance– Laboratory Services (Codes 80048-89356)– Patient Categories (formerly Patient Administration)– Pharmaceuticals (formerly Pharmacy Services)– Pre-Authorizations/Pre-Certifications– Providers– Rate Tables– Third Party Collection Program – Report on Program Results (DD Form 2570)– UBO Metrics Report

8

Document Change History, Priority 1Published 13 Dec 2013, cont.

• Deleted Sections

– Billable Encounters replaced with Billing Inpatient Services and Billing

Outpatient Services

– Inpatient Fiscal Year Rates

– Outpatient Services Not Related to Inpatient

– Admissions Technicians, Nurses, and “Incident To”

• Changed TMA to DHA in all sections except those that were not revised

in this update

• Note: Footer date is date of last User Guide review/change. Each section

contains its last revision date.

9

HIGHLIGHTS OF REVISIONS(published 13 DEC 2013)

10

Ambulatory Procedure Visits (APVs) (Revised)

• 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 charge• After transition to future billing system, ABACUS:

– Do not use 99199– Use Ambulatory Payment Classification (APC) charges for institutional

costs at bedded MTFs– Use Ambulatory Surgery Center (ASC) charges for institutional costs at

nonbedded MTFs– Bill the professional, ancillary, DME, ambulance charges separately

11

Billing Inpatient Services (New)

• 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%) charges

• Do not bill separately for professional charges including if admitted from the emergency department

– For inpatient services provided to USCG beneficiaries, USCG makes prospective payments to all Services and NCR MD

• Do not bill USCG; bill OHI, if any

– Bill non-Active Duty beneficiaries receiving inpatient services at the Family Member Rate (FMR) except:

• Family members of Active Duty members enrolled in TRICARE Prime

• Members whose OHI has been billed12

Billing Inpatient Services (New), cont.

• After transition to future billing system, ABACUS:

– The MS-DRG payment will be based on the TRICARE ASA

– Submit, both, institutional UB-04/837I and professional 1500/837P claims

– Prospective payments to USCG continue; bill OHI only

– Continue to charge FMR as outlined in previous slide

13

Billing Outpatient (New) and Emergency Department Services (Revised)

• Current revised version:

– Rates are specific to an MTF’s locality and the Provider Class

– Rates for Emergency Department (ED) evaluation and management

(E&M) codes 99281-99285 represent institutional charges

• Cannot bill for ED professional services due to MHS system

limitations

– Cannot bill for a service or supply if no rate

• Confirm with system administrator that the most current and

updated version of rates files and tables have been loaded

• May submit rate request using “Process to Request Out-of-Cycle DHA

UBO Rates”14

Billing Outpatient (New) andEmergency Department Services (Revised)

• After transition to future billing system, ABACUS:

– Rates will be specific to an MTF’s locality and the TRICARE Provider

Category

– Submit both institutional and professional claims for ED E&M services

• Use 1500/837P for 99281-99285 professional charges

• Use UB-04/837I for APC-based institutional charges

– Cannot bill for a service or supply if no rate

• Confirm with system administrator that the most current and

updated version of rates files and tables have been loaded

• May submit rate request using “Process to Request Out-of-Cycle DHA

UBO Rates”15

Billing US Coast Guard (New)

• USCG reimburses all Services and NCR MD annually with lump sum

prospective payments

– Do not bill USCG except as noted below

– Collect OHI and bill payers

– Submit claims to USCG beneficiaries for

• Patient 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 collection

– Do not submit claims for USCG PATCAT C44 (USCG GAM MBR

TRANSITIONAL COMP) or Medicare-eligible USCG beneficiaries16

VA-DOD Billing (new)

• For PATCAT K61-2 patients (DOD/VA Sharing Agreement), follow national

and local resource sharing agreement(s), if any

– Use the DHA UBO Inpatient Institutional Calculator package effective on

the patient’s date of service

• Includes CHCS menu path to identify inpatient professional services

– Use the DHA UBO Outpatient Billing Guide effective on the patient’s date

of service

– Use the DHA UBO VA-DOD Sharing Pharmacy Price Estimator (PPE)

effective on the pharmaceutical fill date

• For K61-1 patients (Veterans Administration Beneficiary) follow Billing

Inpatient and Outpatient Services17

File and Table Maintenance (Revised) and Pharmaceuticals (Revised)

• Describes all UBO and non-UBO tables and files essential for accurate, up-to-date billing

– Ensure that the system administrator has received and downloaded the most current and updated versions

• New: Pharmaceutical rates package includes: Billers Edition information to translate dosage and unit measure prices and also TRICARE preauthorization list

– Cannot bill if no rate for the NDC dispensed

• May 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 loaded

• New: Contact external provider for pharmaceutical diagnosis code if payer requires and code does not flow from billing system

18

Helpdesk (revised)

• Removed from the appendix and inserted in the guide

• Contact MTF, Region or Service Program Manager first, then DHA UBO, VPOC or MHS helpdesks as applicable

• DO not send PHI/PII

– “Review all e-mails 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 available

– http://www.tricare.mil/ocfo/mcfs/ubo/learning_center.cfm

– http://www.tricare.mil/tma/privacy/MilitaryHealthSystemLearningPortal.aspx

– https://mhslearn.csd.disa.mil/ilearn/en/learner/mhs/portal/home.jsp 19

Third Party Collection Program Report on Program Results(DD Form 2570 and UBO Metrics Report) (Revised)

• Menu paths for DD 2570 data fields

– TPOCS menu path for outpatient billing and collection data

– CHCS menu path for inpatient Non Active Duty (NAD) data

• Added 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

http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/training.cfm

20

HIGHLIGHTS OF REVISIONS(to be published)

21

Compliance (Revised)

• Compliance plan and designation of compliance officer required

• MTF billing personnel must provide Compliance Officer with all requested

information to complete Compliance Audit Checklists and worksheets

– Minimum baseline examples of the items to be assessed are available at

http://www.tricare.mil/ocfo/mcfs/ubo/policy_guidance/letters.cfm.

– Review these documents to understand your program’s audit

requirements

• New: “The MTF must correct any errors or deficiencies identified during the

Compliance Audit.”

22

Evaluation and Management (Revised)

• Emergency Department E&M CPT® codes 99281 – 99285

– Current version: charges based on institutional APC rate; bill using UB-

04/837I

– After transition to future billing system, ABACUS: charges based on

TRICARE CMAC rates; bill using CMS 1500/837P

• Revised version adds:

– DHA UBO rates for inpatient (CPT® 99251- 99255) and outpatient

consultation codes (CPT® 99241- 99245) are set to zero ($0.00). Thus, do

not bill, and consult with coding personnel for review and correction.

23

Medical Affirmative Claims (Revised)

• 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 Manual

– Work with RJA to provide support for claims

– Use DHA UBO inpatient, outpatient, and pharmacy rates once approved

by the Office of Management and Budget (OMB)

24

SIT/OHI (Revised)(Formerly Health Insurance)

• MTFs should collect OHI with DD Form 2569 annually and verify/update

with the beneficiary at every visit

• Maintain subscription to DEERS for most up-to-date OHI information

• Review for current OHI before updating/entering

• Do not enter placeholder information

– New: “Report any OHI MTF previously entered that has been changed or

incorrectly entered to [email protected]. Include all data

elements in question.”

25

SIT/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 system– Incorrect OHI termination, which prevents billable encounters from

feeding to the billing system– Incorrect OHI rank assignment, which causes initial billing to incorrect

payer– Entry of Placeholder Coverage ID / Placeholder HIC ID, which causes un-

billable encounters to clog the billing system – Misclassification 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 system

– Potentially billing non-billable payers 26

US Family Health Plan (revised)

• Members agree to use 1 of 6 organizations that sponsor the USFHP, in different regions, throughout the United States

• New: Members may not use MTFs unless:– Emergency

• USFHP 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 at http://www.usfhp.com/contact-us/

– Referral• Requires 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.

27

Appendices

• Updated to follow current information in DHA UBO training modules and to delete redundancies

– B: UB-04

– C: CMS-1500

– D: UCF

– E: DD7A instructions

– F: DD7 Instructions

– G: Invoice and Receipts

• Instructions 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 http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/teleconferences.cfm

28

Wrap-Up

• After transition to future billing system, ABACUS:

– Do not use 99199; use APC and ASC for institutional charges

– Submit both 837I and 837P claims for inpatient institutional and inpatient professional including ED E&M 99281-99285 services

– Continue to charge FMR, unless family member of AD TRICARE Prime member or if OHI billed

– Use TRICARE provider categories and appropriate rates for professional services charges

– Continue to ensure system administrator has received and downloaded the most current version of rate files and tables

– Continue to maintain current DEERS subscription; and verify OHI

– Continue to report any changed, modified, or incorrect OHI, previously entered, to [email protected].

– Continue to use menu paths available for inpatient professional services and DD 2570 data fields

29

Wrap-Up, cont.

30

• After transition to future billing system, ABACUS− Continue not to bill if rate is $0.00, unless DHA UBO Program Office

approves a rate request− Prospective payments to USCG continue; bill only OHI and patients directly

for elective cosmetic surgery and newborns of former USCG members or sponsor’s daughters

− Continue to use DHA UBO VA-DOD Resource Sharing: Inpatient Institutional Calculator, Outpatient Billing Guide, and PPE

− Continue to correct any errors or deficiencies identified during the Compliance Audit

− Continue to work with coding personnel for review and correction of inpatient and outpatient consultation codes

− Continue to work with RJA to provide support for MAC claims and use OMB approved rates

− Continue to notify USFHP POC as soon as billing office learns of USFHP emergency encounter

Questions & Answers

31

Instructions 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) e-mail address– View the entire broadcast– After 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 e-mail to participants who logged in or e-mailed as required. This may take several business days.

• Archived webinar (Post-Test required)– View the entire archived webinar (free and available on demand at http://

www.tricare.mil/ocfo/mcfs/ubo/learning_center/training.cfm)– Complete a post-test available within the archived webinar– E-mail answers to [email protected]– If you receive a passing score of at least 70%, we will e-mail MHS personnel with a .mil email address a Certificate of Approval

including an AAPC Index Number

• The 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 AAPC

• For 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. 32