3.0 POLICY
3.1 To receive
TRICARE reimbursement under the OPPS providers must follow and contractors
shall enforce all Medicare specific coding requirements.
3.2 Packaging of Services Under
APC Groups
3.2.1 The prospective payment system establishes
a national payment rate, standardized for geographic wage differences,
that includes operating and capital-related costs that are directly
related and integral to performing a procedure or furnishing a service
on an outpatient basis. These costs include, but are not limited
to:
• Use
of an operating suite.
• Procedure room or
treatment room.
• Use
of the recovery room or area.
• Use of an observation
bed.
• Anesthesia,
certain drugs, biologicals, and other pharmaceuticals; medical and
surgical supplies and equipment; surgical dressings; and devices
used for external reduction of fractures and dislocations.
• Supplies and equipment
for administering and monitoring anesthesia or sedation.
• Intraocular lenses
(IOLs).
• Capital-related
costs.
• Costs
incurred to procure donor tissue other than corneal tissue.
• Incidental services.
• Implantable items
used in connection with diagnostic X-ray testing, diagnostic laboratory
tests, and other diagnostics.
• Implantable prosthetic
devices (other than dental) which replace all or part of an internal
body organ (including colostomy bags and supplies directly related
to colostomy care), including replacement of these devices.
• Certain laboratory
services.
3.2.2 Costs associated with certain
expensive procedures and services are not packaged within an APC
payment rate. Instead, separate APC payment will be made for these
particular items and services under the OPPS. Additional payments
will be provided for certain packaged medical devices, drugs, and
biologicals that are eligible for transitional pass-throughs (i.e.,
payments for expensive drugs or devices that are temporarily reimbursed
in addition to the APC amount for the service or procedure to which
they are normally associated).
3.2.2.1 Costs of
drugs, biologicals and devices packaged into APCs to which they
are normally associated. The costs of drugs, biologicals and pharmaceuticals
are generally packaged into the APC payment rate for the primary
procedure or treatment with which the drugs are usually furnished.
No separate payment is made under the OPPS for drugs, biologicals
and pharmaceuticals whose costs are packaged into the APCs with
which they are associated.
3.2.2.1.1 For the
drugs paid under the OPPS, hospitals can bill both for the drug
and for the administration of the drug.
3.2.2.1.2 The overhead
cost is captured in the administration codes, along with the costs
of all drugs that are not paid for separately.
3.2.2.1.3 Each time
a drug is billed with an administration code, the total payment
thus includes the acquisition cost for the billed drug, the packaged
cost of all other drugs and the overhead.
3.2.2.2 Separate
payment of drugs, biologicals and devices outside the APC amounts
of the services to which they are normally associated.
3.2.2.2.1 Special
transitional pass-through payments (additional payments) made for
at least 2 years, but not more than three years for the following
drugs and biologicals:
• Current orphan drugs,
as designated under section 526 of the Federal Food, Drugs, and
Cosmetic Act;
• Current
drugs and biological agents used for treatment of cancer;
• Current radiopharmaceutical
drugs and biological products; and
• New drugs and biologic
agents in instances where the item was not being paid as a hospital
outpatient service as of December 31, 1996, and where the cost of
the item is “not insignificant” in relation to the hospital OPPS
payment amount.
Note: The process to
apply for transitional pass-through payment for eligible drugs and
biological agents can be found on the Centers for Medicare and Medicaid
Services (CMS) web site:
http://www.cms.gov.
The TRICARE contractors will not be required to review applications
for pass through payment.
3.2.2.2.2 Separate
APC payment for drugs and radiopharmaceuticals for which the median
cost per line exceeds an amount determined each year by Medicare,
and published in the Medicare final rule ($95 for CY 2015 $100 for
CY 2016), with the exception of injectable and oral forms of antiemetics.
3.2.2.2.3 Separately
payable radiopharmaceuticals, drugs and biologicals classified as
“specified covered outpatient drugs” for which payment was made
on a pass-through basis on or before December 31, 2002, and a separate
APC exists.
3.2.2.2.4 Separate
payment for new drugs and biologicals that have assigned Healthcare Common
Procedure Coding System (HCPCS) codes, but that do not have a reference
Average Wholesale Price (AWP), approval for pass-through payment
or hospital claims data.
3.2.2.2.5 Drugs and
biologicals that have not been eligible for pass-through status
but have been receiving nonpass-through payments since implementation
of the Medicare OPPS.
3.2.2.2.6 Separate
payment for new drugs, biologicals and radiopharmaceuticals enabling hospitals
to begin billing for drugs and biologicals that are newly approved
by the U.S. Food and Drug Administration (FDA), and for which a
HCPCS code has not yet been assigned by the National HCPCS Alpha-Numeric
Workgroup.
3.2.2.2.7 Special
APC groups that have been created to accommodate payment for new technologies.
The drugs, biologicals and pharmaceuticals that are incorporated
into these new technology APCs are paid separately from, and in
addition to, the procedure or treatment with which they are associated
yet are not eligible for transitional pass-through payment. Payment
of new technology APC’s is available only if the service meets the
requirements of
32 CFR 199.4.
3.2.2.2.8 New drugs,
biologicals, and devices which qualify for separate payment under
OPPS, but have not yet been assigned to a transitional APC (i.e.,
assigned to a temporary APC for separate payment of an expensive
drug or device) will be reimbursed under TRICARE standard allowable
charge methodology. This allowable charge payment will continue
until a transitional APC has been assigned (i.e., until CMS has
had the opportunity to assign the new drug, biological or device
to a temporary APC for separate payment).
Note: The contractors will not be held accountable for
the development of transitional APC payments for new drugs, biologicals
or devices.
3.2.2.3 Corneal
tissue acquisition costs.
• Corneal tissue acquisition
costs not packaged into the payment rate for corneal transplant
surgical procedures.
• Separate payment will
be made based on the hospital’s reasonable costs incurred to acquire
corneal tissue.
• Corneal
acquisition costs must be submitted using HCPCS code V2785 (Processing, Preserving
and Transporting Corneal Tissue), indicating the acquisition cost
rather than the hospital’s charge on the bill.
3.2.2.4 Costs for
other procedures or services not packaged in the APC payment.
• Blood
and blood products, including anti-hemophilic agents.
• Casting, splinting
and strapping services.
• Immunosuppressive
drugs for patients following organ transplant.
• Certain other high
cost drugs that are infrequently administered.
Note: New APC groups have been created for these items
and services, which allows separate payment.
3.2.2.5 Reporting
Requirements for Device Dependent Procedures.
Hospitals
are required to bill all device-dependent procedures using the appropriate HCPCS
C-codes for the devices. Following are provisions related to the
required use of C-codes:
3.2.2.5.1 Hospitals
are required to report device category codes on claims when such
devices are used in conjunction with procedure(s) billed and paid
for under the OPPS in order to improve the claims data used annually
to update the OPPS payment rates.
3.2.2.5.2 The Outpatient
Code Editor (OCE) will include edits to ensure that certain procedure codes
are accompanied by an associated device category code:
3.2.2.5.2.1 These edits
will be applied at the Current Procedural Terminology (CPT) and
HCPCS I and II code levels rather than at the APC level.
3.2.2.5.2.2 They will
not apply when a procedure code is reported with a modifier 52,
73, or 74 to designate an incomplete procedure.
3.2.2.5.3 Composite
APCs provide a single payment when more than one of a specified
set of major independent services are provided in a single encounter.
When HCPCS codes that meet certain criteria for payment of the composite
APC are billed on the same date of service, CMS makes a single payment
for all of the codes as a whole, rather than paying individually
for each code. For those services considered to be a TRICARE benefit,
TRICARE will adopt the composite APC logic as established by Medicare.
See the Medicare Claims Processing Manual, Chapter 4, Section 10.2.1
for current composite APC logic. See the TRICARE rates web site
at
http://www.health.mil/rates for
the national unadjusted payment rates for these composite APCs.
3.2.2.5.4 Comprehensive
APCs provide a single payment for a primary service, and payment
for all adjunctive services reported on the same claim are packaged
into payment for the primary service. With some exceptions, all
other services reported on a hospital outpatient claim in combination
with the primary service are considered to be related to the delivery
of the primary service and packaged into the single payment for
the primary service. HCPCS codes assigned to comprehensive APCs
are designated with Status Indicator (SI)
J1. When
multiple
J1 services are reported on the same claim,
the single payment is based on the rate associated with the highest
ranking
J1 service. When certain pairs of
J1 services,
or in certain cases a
J1 service and add-on code, are
reported on the same claim, the claim is eligible for a complexity
adjustment, which provides a single payment for the claim based
on the rate of the next higher comprehensive APC within the same
clinical family. Please see the Medicare Claims Processing Manual,
Chapter 4, Section 10.2.3 for detailed logic for comprehensive APCs, including
descriptions of those services included in the comprehensive APC
payment, and those limited exceptions. For those services considered
to be a TRICARE benefit, TRICARE will adopt the comprehensive APC
logic as established by Medicare. See the TRICARE rates web site
at
http://www.health.mil/rates for
the national unadjusted payment rates for comprehensive APCs.
3.2.2.5.5 Beginning
January 1, 2016, all qualifying extended assessment and management encounters
will be paid through a newly created “comprehensive observation
service” C-APC. Please see
paragraph 3.9 for more information.
3.3 Additional
Payments Under The OPPS
3.3.1 Certain clinical diagnostic
testing (lab work).
3.3.2 Administration of infused
drugs.
3.3.3 Therapeutic procedures including resuscitation
that are furnished during the course of an emergency visit.
3.3.4 Certain
high-cost drugs, such as the expensive “clotbuster” drugs that must
be given within a short period of time following a heart attack
or stroke.
3.3.5 Cases that fall far outside the normal range
of costs. These cases will be eligible for an outlier adjustment.
3.4
Payment
For Patients Who Die In The Emergency Department (ED)
3.4.1 If the
patient dies in the ED, and the patient’s status is outpatient,
the hospital should bill for payment under the OPPS for the services
furnished.
3.4.2 If the ED or other physician orders the patient
to the operating room for a surgical procedure, and the patient
dies in surgery, payment will be made based on the status of the
patient.
• If
the patient had been admitted as an inpatient, pay under the hospital
DRG-based payment system.
• If the patient was
not admitted as an inpatient, pay under the OPPS (an APC-based payment)
for the services that were furnished.
• If the patient was
not admitted as an inpatient and the procedure designated as an inpatient-only
procedure (by OPPS payment SI of C) is performed, the
hospital should bill for payment under the OPPS for the services
that were furnished on that date and should include modifier -CA
on the line with the HCPCS code for the inpatient procedure. Payment
for all services other than the inpatient procedure designated under
OPPS by the SI of C, furnished on the same date, is
bundled into a single payment under APC 0375. Beginning January
1, 2016, APC 0375 will be renumbered to APC 5881, and all services
reported on the same claim as an inpatient only procedure with modifier
-CA will be paid through a single prospective payment for the comprehensive
service.
3.4.3 Billing and Payment Rules
for Using Modifier -CA. Procedure payable only in the inpatient setting
when performed emergently on an outpatient who dies prior to admission.
3.4.3.1 All the
following conditions must be met in order to receive payment for
services billed with modifier -CA:
• The status of the
patient is outpatient;
• The patient has an
emergent, life-threatening condition;
• A procedure on the
inpatient list (designated by payment SI of C) is performed
on an emergency basis to resuscitate or stabilize the patient; and
• The patient dies without
being admitted as an inpatient.
3.4.3.2 If all
of the conditions for payment are met, the claim should be submitted
using a 013X bill type for all services that were furnished, including
the inpatient procedure (e.g., a procedure designated by OPPS payment
SI of
C). The hospital should include modifier -CA
on the line with the HCPCS code for the inpatient procedure.
Note: When a line with a procedure code that has a SI
of C assigned and has a patient status of “20” (deceased)
and one of the modifiers is “CA” (patient dies). The OCE software
will change the SI of the procedure to S and price
the line using the adjusted APC rate formula.
3.4.3.3 Payment
for all services on a claim that have the same date of service as
the HCPCS billed with modifier -CA is made under APC 0375. Separate
payment is not allowed for other services furnished on the same
date.
3.4.3.4 Beginning
January 1, 2016, APC 0375 will be renumbered to APC 5881, and all
services reported on the same claim as an inpatient only procedure
with modifier -CA will be paid through a single prospective payment
for the comprehensive service.
3.5 Medical Screening
Examinations
3.5.1 Appropriate ED codes will be used for medical
screening examinations including ancillary services routinely available
to the ED in determining whether or not an emergency condition exists.
3.5.2 If no treatment
is furnished, medical screening examinations would be billed with
a low-level ED code.
3.6 HCPCS/Revenue Coding Required
Under OPPS
Hospital Outpatient Departments
(HOPDs) should use the CMS 1450 UB-04 Editor as a guide for reporting
HCPCS and revenue codes under the OPPS.
3.7
Treatment
of Partial Hospitalization Programs (PHPs) And Intensive Outpatient
Programs (IOPs)
Hospital-based PHPs and IOPs
for mental health and Substance Use Disorder (SUD) treatment shall be
reimbursed a per diem payment under the OPPS. Freestanding PHPs and
IOPs are reimbursed under the PHP and IOP per diem payment. See
Chapter 7. Separate TRICARE authorization of
hospital-based PHPs and IOPs is not required, making all hospital-based
PHPs and IOPs eligible for payment under TRICARE’s OPPS.
3.7.1 Services
of physicians, clinical psychologists, Clinical Nurse Specialists
(CNSs), Nurse Practitioners (NPs), and Physician Assistants (PAs)
furnished to PHP or IOP beneficiaries are billed separately as professional
services and are not considered to be PHP or IOP services.
3.7.2 Payment
for PHP or IOP services represents the provider’s overhead costs,
support staff, and the services of Certified Clinical Social Workers
(CCSWs) and Occupational Therapists (OTs), whose professional services
are considered to be included in the PHP or IOP per diem rate. For PHP
and IOP SUD treatment, the costs of alcohol and addiction counselor
services shall also be included in the per diem.
• Hospitals shall not
bill the contractor for the professional services furnished by CCSWs, OTs,
and alcohol and addiction counselors.
• Rather, the hospital’s
costs associated with the services of CSWs, OTs, and alcohol and addiction
counselors shall continue to be billed to the contractor and paid
through the per diem rate.
3.7.3 PHP should
be a highly structured and clinically-intensive program, usually
lasting most of the day. IOP is a comprehensive and complementary
schedule of recognized treatment approaches that may include day,
evening, night, and weekend services consisting of individual and
group counseling or therapy, and family counseling or therapy as
clinically indicated for children and adolescents, or adults aged
18 and over, and may include case management to link patients and
their families with community-based support systems. Since a day
of care is the unit that defines the structure and scheduling of PHP services,
a two-tiered payment approach has been retained to reflect the lower
costs of a less intensive day. IOP may be appropriate for patients
who do not require the more intensive level of care, or for those
who have completed a more intense inpatient or partial hospitalization
stay.
3.7.3.1 For dates of service prior to October 3, 2016,
it was never the intention of this two-tiered per diem system that
only three units of service should represent the number of services
provided in a typical day. The intention of the two-tiered system
was to cover days that consisted of three units of service only
in certain limited circumstances; e.g., three-service days may be
appropriated when a patient is transitioning towards discharge or
days when a patient who is transitioning at the beginning of their PHP
stay.
3.7.3.1.1 Programs
that provide four or more units of service should be paid an amount
that recognizes that they have provided a more intensive day of
care. A higher rate for more intensive days is consistent with the
goal that hospitals provide a highly structured and clinically-intensive
program.
3.7.3.1.2 For dates
of service prior to October 3, 2016, the OCE logic will require
that hospital-based PHPs provide a minimum of three units of service
per day in order to receive PHP payment. Payment will be denied
for days when fewer than three units of therapeutic services are
provided. The three units of service are a minimum threshold that
permits unforeseen circumstances, such as medical appointments,
while allowing payment, but still maintains the integrity of a comprehensive
program. An exception to the requirement for three units for service
is made for programs billing with HCPCS codes S9480 or H0015. Because
these codes represent comprehensive programs, they must represent
a program providing at a minimum three hours of service per day.
3.7.3.2 For
dates of service on or after October 3, 2016, and before January
2017:
3.7.3.2.1 The OCE logic will require that hospital-based
PHPs and IOPs provide a minimum of two units of service per day
in order to receive payment. An exception to the requirement for
two units of service is made for programs billing with HCPCS codes
S9480 and H0015. Because these codes represent comprehensive programs,
they must represent a program providing at a minimum two hours of
service per day.
3.7.3.2.2 PHP programs
providing either two or three hours of service per day, or those
claims with HCPCS codes S9480 and H0015 shall be grouped to APC
05861. PHP programs providing four or more hours of service shall
continue to group to APC 05862.
3.7.3.3 For dates of service on or after January 1,
2017, in accordance with Medicare’s Calendar Year (CY) OPPS Final
Rule (81 FR 79562), APCs 05861 and 05862 are deleted. Although Medicare
now only recognizes one level of PHP care (three units of service
or more), TRICARE will retain a two-tiered system, with the lower
tier consisting of: two hours of service which will group to APC
T5861; or one occurrence of an IOP code (HCPCS codes S9480 or H0015)
which will group to T0175. Three or more units of service shall
group to the newly created APC 05863.
3.7.3.4 The following
are billing instructions for submission of partial hospitalization
claims/services:
3.7.3.4.1 Hospitals
are required to use HCPCS codes and report line item dates for their
partial hospitalization services. This means that each service (revenue
code) provided must be repeated on a separate line item along with
the specific date the service was provided for every occurrence.
3.7.3.4.2 A complete
listing of the revenue codes and HCPCS codes that may be billed
as partial hospitalization services or other mental health services
outside partial hospitalization is available in the Medical Claims
Processing Manual Chapter 4, Section 260.1.
3.7.3.4.3 To bill
for partial hospitalization services under the hospital OPPS, hospitals
are to report partial hospitalization services under bill type 013X,
along with Condition Code 41 on the CMS 1450 UB-04 Claim Form.
3.7.3.4.4 The claim
must include a mental health diagnosis and an authorization on file
for each day of service. Since there is no HCPCS code that specifies
a partial hospitalization related service, partial hospitalizations
are identified by means of a particular bill type and condition
code (i.e., 13X Type Of Bill (TOB) with Condition Code 41) along
with HCPCS codes specifying the individual services that constitute
PHPs.
3.7.3.4.4.1 For dates
of service prior to October 3, 2016, in order to be assigned payment
under Level I Partial Hospitalization Payment APC (0175 renumbered
to APC 05861) there shall be at least three codes from PHP List
B of which at least one code must come from PHP List A. For payment
under Level II Partial Hospitalization Payment APC (05862), there
shall be four or more codes from PHP List B of which at least one
code must come from PHP List A. List A is a subset of List B and
contains only psychotherapy codes, while List B includes all PHP
codes. (Refer to PHP Lists A and B in
Figure 13.2-1). All other PHP
services rendered on the same day shall be packaged into the PHP
APCs (0175 and 0176, renumbered to 05861 and 05862). All PHP lines
shall be denied if there are less than three codes/service appearing
on the claim.
3.7.3.4.4.2 For dates
of service on or after October 3, 2016 and before January 1, 2017,
in order to be assigned payment under APC 05861, there shall be
at least two codes from PHP List B, or which at least one code must
come from PHP List A. Payment under APC 05862 requires a least three
codes from PHP List B, of which at least one code comes from PHP
List A. All other PHP services rendered on the same day shall be
packaged into PHP APCs 05861 or 05862.
3.7.3.4.4.3 For dates of service on or after January 1,
2017, Medicare has deleted APCs 05861 and 05962, eliminating the
two-tiered approach. However, TRICARE considers two hours of PHP
a covered benefit. Therefore, TRICARE will retain the two-tiered
approach, with days consisting of at least three hours of service
(with at least one unit from PHP List A) assigned to APC 05863.
Figure 13.2-1 PHP
As Of CY 2015
|
PHP List
A
|
PHP
List B
|
PHP List
C*
|
|
*
Add-on codes that are not counted in meeting the numerical requirement
for APC assignment.
|
|
90832
|
90785
|
|
90785
|
|
90834
|
90791
|
96101
|
90833
|
|
90837
|
90792
|
96102
|
90836
|
|
90845
|
90832
|
96103
|
90838
|
|
90846
|
90833
|
96116
|
|
|
90847
|
90834
|
96118
|
|
|
90865
|
90836
|
96119
|
|
|
|
90837
|
96120
|
|
|
G0410
|
90838
|
|
|
|
G0411
|
90845
|
G0176
|
|
|
|
90846
|
G0177
|
|
|
|
90847
|
G0410
|
|
|
|
90865
|
G0411
|
|
3.7.3.4.5 In order to assign the partial hospitalization
APC to one of the line items the payment APC for one of the line
items that represent one of the services that comprise partial hospitalization
is assigned the partial hospitalization APC. All other partial hospital
services on the same day are packaged; (i.e., the SI is changed
from Q to N.) Partial hospitalization
services with SI E (items or services that are not
covered by TRICARE) or B (more appropriate code required
for TRICARE OPPS) are not packaged and are ignored in the PHP processing.
See the Medicare Claims Processing Manual, Chapter 4, Section 260.1
for additional details on PHP claims processing in hospitals subject
to OPPS.
3.7.3.4.6 Each day
of service will be assigned to a partial hospitalization APC, and
the partial hospitalization per diem will be paid. Only one PHP
APC will be paid per day.
3.7.3.4.7 Non-mental health services submitted on the
same day will be processed and paid separately.
3.7.3.4.8 Hospitals
must report the number of times the service or procedure was rendered,
as defined by the HCPCS code.
3.7.3.4.9 Dates of service per revenue code line for
partial hospitalization claims that span two or more dates. Each
service (revenue code) provided must be repeated as a separate line
item along with the specific date the service was provided for every
occurrence. Line item dates of service are reported in “Service
Date.” Following are examples of reporting line item dates of service.
These examples are for group therapy services provided twice during
a billing period.
Figure 13.2-2 Reporting Of Partial Hospitalization
Services Spanning Two Or More Dates - HIPAA 837 Format
|
Record
Type
|
Revenue
Code
|
HCPCS
|
Dates
Of Service
|
Units
|
Total
Charge
|
|
61
|
0915
|
90849
|
19980505
|
1
|
$80
|
|
61
|
0915
|
90849
|
19980529
|
2
|
$160
|
Figure 13.2-3 Reporting Of Partial Hospitalization
Services Spanning Two Or More Dates - CMS 1450 Format
|
Revenue
Code
|
HCPCS
|
Dates
Of Service
|
Units
|
Total
Charges
|
|
0915
|
90849
|
050598
|
1
|
$80
|
|
0915
|
90849
|
052998
|
2
|
$160
|
Note: Each line item
on the CMS 1450 UB-04 Claim Form must be submitted with a specific
date of service to avoid claim denial. The header dates of service
on the CMS 1450 UB-04 may span, as long as all lines include specific
dates of service within the span on the header.
3.7.4 Reimbursement
for a day of outpatient mental health services in a non-PHP program
(i.e., those mental health services that are not accompanied with
a Condition Code 41) will be capped at the partial hospital per
diem rate. The payments for all of the designated Mental Health
(MH) services will be totaled with the same date of service. If
the sum of the payments for the individual MH services standard
APC rules, for which there is an authorization on file, exceeds
the Level II Partial Hospitalization APC (0176), a special MH services
composite payment APC (APC 0034) will be assigned to one of the
line items that represent MH services. All other MH services will
be packaged. The MH services composite payment APC amount is the
same as the Level II Partial Hospitalization APC per diem rate.
MH services with SI E or B are not included
in payments that are totaled and are not assigned the daily mental
health composited APC amount.
3.7.5 Beginning January 1, 2016,
APC 0175 and 0176 are renumbered to 5861 and 5862, respectively.
3.8 Reimbursement
of Opioid Treatment Programs (OTPs)
3.8.1 Effective for dates of service
on or after October 3, 2016, hospital-based OTPs shall be reimbursed
either a weekly all-inclusive rate or on a fee-for-service basis,
depending on the type (methadone versus other pharmaceuticals) and
frequency of services.
3.8.1.1 Methadone
OTPs shall be reimbursed a weekly all-inclusive rate.
3.8.1.2 The weekly all-inclusive rate shall include
the cost of the drug and all related services (i.e., the costs related
to initial intake/assessment, drug dispensing and screening, and
integrated psychosocial and medical treatment and support services.)
3.8.1.3 The weekly all-inclusive rate shall be accepted
as payment-in-full.
3.8.1.4 The weekly
all-inclusive rate is subject to the outpatient cost-sharing provisions
in
32 CFR 199.4(f). Services shall be cost-shared
on a weekly basis (e.g., one $12 cost-share applies to a full week of
methadone OTP services for a Prime retiree).
3.8.1.5 For Fiscal Year (FY) 2017, the national weekly
all-inclusive rate shall be $126.
3.8.1.6 The weekly all-inclusive rate shall be wage-adjusted
using the provisions established in this Chapter.
3.8.1.7 The weekly all-inclusive set of services shall
be billed utilizing HCPCS code H0020 [Alcohol and/or drug
services]. Only one occurrence of this code shall be reimbursed
in a given week.
3.8.1.8 HCPCS code
H0020 shall be assigned to a TRICARE-specific APC, which will be
assigned a payment rate in accordance with this paragraph. The APC
rate shall be updated in accordance with the provisions of this
Chapter.
3.8.2 When
providing other medications (e.g., Buprenorphine and Naltrexone),
OTPs shall be reimbursed on a fee-for-service basis (i.e., separate
payments will be allowed for both the medication and accompanying
support services).
3.8.2.1 Buprenorphine.
HCPCS code H0047 shall be utilized to reflect the medical/intake
and assessment, drug dispensing and monitoring and counseling services.
H0047 shall be reimbursed in accordance with the CHAMPUS Maximum
Allowable Charge (CMAC) methodology; see
Chapter 5, Section 3.
HCPCS code H0047 shall be assigned to an SI of A for TRICARE. The
appropriate HCPCS code shall be utilized to bill for the medication,
and shall be assigned an SI of A for TRICARE. See
Chapter 1, Section 15.
3.8.2.2 Naltrexone. HCPCS code H0047 shall be utilized
to reflect the medical/intake and assessment, monitoring and counseling
services. H0047 shall be reimbursed in accordance with the CMAC
methodology; see
Chapter 5, Section 3.
H0047 shall be assigned to an SI of A for TRICARE. CPT code 96372
shall be utilized to report the administration fee. The appropriate
HCPCS code shall be utilized for the prescribed medication. In general,
Naltrexone is provided as an injection every four weeks. Contractors
shall review more frequent administration to ensure services are
medically necessary and appropriate. See
Chapter 1, Section 15.
3.8.3 Cost-sharing. Services provided under
paragraph 3.8.2 are
subject to the outpatient cost-sharing provisions in
32 CFR 199.4(f). Cost-sharing shall be applied
on a per-visit basis.
3.9
Payment
Policy for Observation Services
3.9.1 Beginning January 1, 2014, in certain circumstances
when observation care is billed in conjunction with a clinical visit,
high level Type A ED visit (level 4 or 5), high level
Type B ED visit (level 5), critical care services,
or a direct referral as an integral part of a patients extended
encounter of care, payment may be made for the entire encounter
through APC 8009. APC’s 8002 and 8003 were deleted as of January
1, 2014. APC 8009 is deleted effective January 1, 2016. See the
Medicare Claims Processing Manual, Chapter 4, Sections 10.2.1, 290.5.1.
and 290.5.2 for observation stays for non-maternity conditions.
3.9.2 Beginning January 1, 2016, all qualifying extended
assessment and management encounters will be paid through a “Comprehensive
Observation Services” Comprehensive -APC (C-APC), 8011, and will
assign the services within this APC to SI of
J2. In
order to be eligible for payment under this C-APC, claims must meet
the following criteria:
• The claims do not
contain a procedure described by a HCPCS code with assigned SI of T that
is reported with a date of service on the same day or one day earlier
than the date of service associated with services described by HCPCS
code G0378;
• The
claims contain eight or more units of services described by HCPCS
code G0378 (Observation services, per hour);
• The claims contain
services described by one of the following codes: HCPCS code G0379
on the same date of service as services described by HCPCS code
G0378; CPT code 99284; CPT code 99285 or HCPCS code G0384; CPT code
99291; or HCPCS code G0463 provided on the same date of service
or one day before the date of service for services described by
HCPCS code G0378; and
• The claims do not
contain services described by a HCPCS code with assigned SI of J1.
• Observations for maternity
conditions that meet the above criteria will be reimbursed utilizing
this logic. See
paragraph 3.9.3 for all other maternity observation
services.
3.9.3
Observations
For Maternity Conditions
3.9.3.1 Maternity
observation stays will continue to be paid separately under TRICARE
APC T0002 using HCPCS code G0378 (Hospital observation services
by hour) if the following criteria are met:
3.9.3.1.2 The number of units reported with HCPCS code
G0378 must be at a minimum four hours per observation stay; and
3.9.3.1.3 No procedure
with a SI of T can be reported on the same day or day
before observation care is provided.
3.9.3.2 If the above criteria are not met, the maternity
observation will remain bundled (i.e., the SI for HCPCS code G0378
will remain N).
3.9.3.3 Multiple maternity observations on a claim
are paid separately if the required criteria are met for each observation
and Condition Code “G0” is present on the claim or
modifier 27 is present on additional lines with HCPCS code G0378.
3.9.3.4 If multiple payable maternity observations
are submitted without Condition Code “G0” or modifier
27, the first encountered is paid and additional observations for
the same day are denied.
3.10
Inpatient
Only Procedures
3.10.1 TRICARE
adopted Medicare’s Inpatient Only List. The inpatient list on DHA’s
OPPS web site at
http://www.health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Inpatient-Procedures specifies
those services that are only paid when provided in an inpatient
setting because of the nature of the procedure, the need for at
least 24 hours of postoperative recovery time or monitoring before
the patient can be safely discharged, or the underlying physical
condition of the patient.
3.10.1.1 The list
is updated quarterly and reflects CMS changes. The Director may
make exceptions to Medicare’s Inpatient Only List and include those
exceptions in the April or October quarterly updates for those inpatient
procedures, which upon medical review, may be safely and efficaciously
rendered in an outpatient setting due to TRICARE’s younger, healthier
beneficiary population. Exceptions will be made based on standardized
utilization review criteria used by the contractors.
3.10.1.1.1 The contractor shall identify those procedures
that they believe should be removed from or added to the list of
inpatient procedures, along with support from standardized utilization management
(UM) review criteria. Requests shall be submitted to the Medical
Benefits & Reimbursement Section (MB&RS) through the applicable
Contracting Officer’s Representative (COR). If standardized UM criteria
are not provided with the request, the Director will not consider
the procedure for modification. Contractors may submit procedures
for consideration at any time; however, to be considered for the
following April or October update, procedures and supporting criteria
must be submitted by January 15 to be considered for the April update,
and by July 15, to be considered for the following October update.
3.10.1.1.2 If the Director’s review determines a modification
to the inpatient list is warranted, the procedure will be assigned
to an appropriate APC and rate. If there is a similar procedure,
with an assigned APC under OPPS, the Director will assign the newly-approved
procedure to that APC with corresponding SI and rate. If there is
no appropriate APC, the Director will create a TRICARE-specific
APC based on a method similar to that of Medicare, which identifies
the geometric mean for all costs for the procedure, and then standardize
those costs to the geometric mean cost of APC 5012 to provide an APC
weight. This weight is then scaled by the Budget Neutrality Factor
required by the Social Security Act, as specified in the annual
CMS OPPS Final Rule. The final APC weight is multiplied by the appropriate
conversion factor to determine the TRICARE-specific APC payment
amount. In the case that no APC amount can be determined based on
claims data, APC T9999 and SI of T will be assigned to the procedure.
When sufficient claims data exist, an APC amount shall be determined
based on the provisions of this paragraph. The final APC weight
and payment amount will be provided to the contractor building the
OPPS pricer for inclusion in the software.
3.10.1.1.3 Effective April 1, 2017, individuals who have
dual eligibility under both TRICARE and Medicare are not eligible
for cost-sharing for TRICARE exceptions to Medicare’s Inpatient
Only List.
3.10.1.1.4 Exceptions
to the Inpatient Only List shall not be made on a case-by-case basis.
The Director’s determination of whether a procedure is removed from
the Inpatient Only List is not based on medical review of individual
beneficiary claims, but on generally accepted medical standards
of practice as substantiated by standardized utilization management
review criteria.
3.10.1.2 Denial
of payment for procedures on the Inpatient Only List is appealable
under the Appeal of Factual (Non-Medical Necessity) Determinations.
Refer to the TRICARE Operations Manual (TOM),
Chapter 12, Section 5 for appeal procedures.
3.10.1.3 Refer to
Chapter 1, Section 16,
for additional information regarding TRICARE’s Inpatient Only List.
3.10.2 Under the hospital outpatient PPS, payment
will not be made for procedures that are designated as “inpatient
only”.
3.10.3 There are
three exceptions to the policy of not paying for outpatient services
furnished on the same day with an “inpatient-only” service that
would be paid under the OPPS if the inpatient service had not been
furnished:
3.10.3.1 For outpatients
who undergo inpatient-only procedures on an emergency basis and
who expire before they can be admitted to the hospital, a specified
APC payment is made to the provider as reimbursement for all services
on that day. The presence of modifier
CA on the inpatient-only procedure
line assigns the specified payment APC and associated status and
payment indicators to the line. The packaging flag is turned on
for all other lines on that day. Payment is only allowed for one procedure
with modifier
CA. If multiple inpatient-only procedures
are submitted with the modifier -CA, only one procedure is paid
and all others are packaged. If multiple units are submitted on
a payable inpatient-only procedure line, the OCE resets the service
units to one. If modifier
CA is submitted with an inpatient-only
procedure for a patient who did not expire (patient status code
is not 20), the claim is suspended for data validation. Beginning
January 1, 2016, APC 0375 will be renumbered to APC 5881, and all
services reported on the same claim as an inpatient only procedure
with modifier -CA will be paid through a single prospective payment
for the comprehensive service. Also, beginning January 1, 2016,
the assignment of the C-APC will be across the claim, rather than
the day. See
paragraph 3.4.3.4.
3.10.3.2 Inpatient-only procedures that are on the separate-procedure
list are bypassed when performed incidental to a surgical procedure
with SI of T. The line(s) with the inpatient-separate procedure
is denied and the claim is processed according to usual OPPS rules.
3.10.3.3 Inpatient-only
procedures are allowed on outpatient claims for Supplemental Health
Care Program (SHCP) beneficiaries. If a line item with an inpatient-only
procedure (SI = C) is reported, the inpatient-only
logic is bypassed for the day and all procedures with SI = C on
the same date of service have their SI changed to T (and
assigned to APC T9999).
3.11 Billing
of Condition Codes Under OPPS
The CMS 1450
UB-04 Claim Form allows 11 values for condition codes, however,
the OCE can only accommodate seven, therefore, OPPS hospitals should
list those condition codes that affect outpatient pricing first.
3.12 Billing
for Wound Care Services
3.12.1 A list
of CPT codes are classified as “sometimes therapy” services that
may be appropriately provided under either a certified therapy plan
of care or without a certified therapy plan of care is located
at
https://www.cms.gov/Medicare/Billing/TherapyServices/.
3.12.2 Hospitals would receive separate payment under
the OPPS when they bill for wound care services listed as “sometimes
therapy” codes that are furnished to hospital outpatients by individuals independent
of a therapy plan of care.
3.12.3 When these services are performed by a qualified
therapist under a certified therapy plan of care, providers should
attach an appropriate therapy modifier (that is, GP for
Physical Therapy (PT), GO for Occupational Therapy
(OT), and GN for Speech-Language Pathology (SLP)) or
report their charges under a therapy revenue code (that is, 0420,
0430, or 0440) or both, to receive payment under the professional
fee schedule.
3.12.4 The OCE
logic assigns these services to the appropriate APC for payment
under the OPPS if the services are not provided under a certified
therapy plan of care or directs contractors to the fee schedule
payment rates if the services are identified on hospital claims
with therapy modifier or therapy revenue code as a therapy service.
3.12.5 See the Medicare Claims Processing Manual,
Chapter 4, Section 200.9 for more information on “sometimes therapy”
codes.