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.