1.0 APPLICABILITY
This policy is mandatory for the reimbursement
of services provided either by network or non-network providers.
However, alternative network reimbursement methodologies are permitted
when approved by the Defense Health Agency (DHA) and specifically
included in the network provider agreement.
3.0 POLICY
Appropriate bill types:
3.1 Bill Types Subject To Outpatient
Prospective Payment System (OPPS)
All outpatient
hospital bills (bill types 013X with Condition Code 41, 013X without
Condition Code 41, 014X for diagnostic services), with the exception
of bills from providers excluded under
Section 1, paragraph 3.4.1.2.5 will be subject
to the OPPS.
3.2 Reporting Requirements
3.2.1 Payment
of outpatient hospital claims will be based on the “from” date on
the claim.
3.2.2 Hospitals should make every effort to report
all services performed on the same day on the same claim to ensure
proper payment under OPPS.
3.2.3 Each line item on the Centers
for Medicare and Medicaid Services (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.
3.3 Procedures for Submitting
Late Charges
3.3.1 Hospitals may not submit a late charge bill
(frequency 5 in the third position of the bill type) for bill types
013X.
3.3.2 They must submit an adjustment bill for any
services required to be billed with Healthcare Common Procedure
Coding System (HCPCS) codes, units, and line item dates of service
by reporting frequency 7 or 8 in the third position of the bill
type. Separate bills containing only late charges will not be permitted.
Claims with bill type 0137 and 0138 should report the original claim
number in Form Location (FL) 64 on the Centers for Medicare and
Medicaid Services (CMS) 1450 UB-04 Claim Form.
3.3.3 The submission
of an adjustment bill, instead of a late charge bill, will ensure
proper duplicate detection, bundling, correct application of coverage
policies and proper editing of Outpatient Code Editor (OCE) under
OPPS.
Note: The contractors will take appropriate
action in those situations where either a replacement claim (Type
of Bill (TOB) 0137)) or voided/canceled claim
(TOB 0138) is received without an initial claim (TOB 0131) being
on file. Adjustments resulting in overpayments will be set for recoupment
allowing an auto offset.
3.4 Claim Adjustments
Adjustments to OPPS claims shall be priced
based on the from date on the claim (using the rules and weights
and rates in effect on that date) regardless of when the claim is
submitted. Contractor’s shall maintain at least three years of APC
relative weights, payment rates, wage indexes, etc., in their systems.
If the claim filing deadline has been waived and the from date is
more than three years before the reprocessing date, the affected
claim or adjustment is to be priced using the earliest APC weights
and rates on the contractor’s system.
3.5 Proper Reporting of Condition
Code G0 (Zero)
Hospitals should report Condition
Code G0 when multiple medical visits occurred on the
same day in the same revenue center but the visits were distinct
and constituted independent visits. Refer to the Medicare Claims
Processing Manual, Chapter 4, Section 180.4 for proper reporting
of Condition Code G0.
3.6
Clinical
Diagnostic Laboratory Services Furnished to Outpatients
3.6.1 Hospitals
should report HCPCS codes for clinical diagnostic laboratory services.
3.6.2 Beginning
January 1, 2014, most laboratory tests will be packaged under OPPS.
Laboratory tests should be reported on TOB 13X. Laboratory tests
may be separately paid when billed on TOB 14X in the following circumstances:
3.6.2.1 Non-patient
laboratory specimen tests.
3.6.2.2 When the
hospital only provides laboratory tests (directly or under arrangement)
and patient receives no other hospital outpatient services during
the same encounter.
3.6.2.3 When the
laboratory test is provided (directly or under arrangement) during
the same encounter as other hospital outpatient services that is
clinically unrelated to the other hospital outpatient services,
and the laboratory test is ordered by a different practitioner than
the practitioner who ordered the other hospital outpatient services.
3.6.3 Beginning January 1, 2016, laboratory
tests (regardless of date of service) on a claim with a service
that is assigned a Status Indicator (SI) of S, T,
or V, unless an exception applies or the laboratory test
is “unrelated” to the other service(s) on the claim, will be conditionally
packaged and will be assigned SI of Q4. When laboratory
tests are the only service(s) on a claim, a separate payment may
be made.
3.7 OPPS Modifiers
TRICARE requires the reporting of HCPCS Level
I and II modifiers for accuracy in reimbursement, coding consistency,
and editing.