3.0 POLICY
3.1 Hospital
Billing
Under
the TRICARE DRG-based payment system, hospitals are required to
submit claims in accordance with
32 CFR 199.7(b).
The contractor shall assign the appropriate DRG to the claim based on
the information contained on the claim.
3.1.1 Hospital
participation. As noted previously, all hospitals which participate
in Medicare are required to participate on all inpatient claims.
3.1.2 Late charges. Any late charges
received by the contractor for a claim which has been processed
under the TRICARE DRG-based payment system shall be processed as
an adjustment. Generally, late charges will not result in any additional
payment, but they could affect payment by changing the DRG assigned
to the claim or by causing the claim to qualify as an outlier, or
they could affect the amount of the beneficiary’s cost-share.
3.1.3 Beneficiary-submitted claims.
If a beneficiary submits a claim which is determined to be subject
to the TRICARE DRG-based payment system (or for services from an
exempt hospital which is Medicare-participating), whether for inpatient
services or for related professional services rendered by a hospital-based
professional, the claim is to be returned (uncontrolled) with the
notation that all inpatient hospital claims must be submitted by
the provider.
3.2 Payment
On A Per Discharge Basis
Under the TRICARE DRG-based
payment system, hospitals are paid a predetermined amount per discharge
for inpatient hospital services furnished to TRICARE beneficiaries.
3.3 Pricing of Claims
3.3.1 All
final claims with discharge dates of September 30, 2014, or earlier
that are reimbursed under the TRICARE DRG-based payment system are
to be priced using the rules, weights and rates in effect as of
the date of admission, regardless of when the claim is submitted.
All final claims with discharge dates of October 1, 2014, or later
that are reimbursed under the TRICARE DRG-based payment system are
to be priced using the rules, weights and rates in effect as of
the date of discharge. Interim claims with end date of care on or
after October 1, 2014, shall be priced using the rules, weights and
rates in effect as of the end date of care. (See the TRICARE Systems
Manual (TSM),
Chapter 2, Section 5.2.)
3.3.2 Contractors shall maintain
at least three years’ weights and rates, including Indirect Medical Education
(IDME) adjustment factors, wage indexes, etc., in the contractor’s
on-line system. If the claim filing deadline has been waived and
the date of discharge is more than three years before the reprocessing
date, the affected claim or adjustment is to be priced using the
earliest DRG weights and rates on the contractor’s system.
3.4
Payment
In Full
The DRG-based
amount paid for inpatient hospital services is the total TRICARE
payment for the inpatient operating costs (as described in this
section) incurred in furnishing services covered by the TRICARE.
The full prospective payment amount is payable for each stay during
which there is at least one covered day of care, except as provided
in
Section 8 for short-stay outliers. Thus, certain
items related or incidental to the treatment of the patient, but
which might not otherwise be covered, are included in the DRG-based
payment. For example, patient education services such as nutrition counseling
are not covered by TRICARE, but if they are provided incidental
to covered services, they are to be considered included in the DRG-based
payment. The hospital cannot bill the beneficiary for the services,
since they are included in the overall treatment regimen for the
admission. At the same time, the contractor is not to reduce the
DRG-based payment simply because some non-covered services were
rendered.
3.4.1 Services received from another
hospital. In those cases in which the hospital obtains certain services
from another hospital (e.g., computerized tomography services) no
additional payment is to be made to either hospital for the technical
component of the services. The technical component is to be considered
part of the DRG-based payment, and it is the discharging hospital’s
responsibility to make suitable payment arrangements with the other
hospital providing services. Of course, the professional component
of such services can be billed separately by the second hospital.
3.4.2 Interim bills for unusually
long Lengths-Of-Stay (LOS). Because the DRG-based payment is the
full payment for the claim, in most cases interim bills will not
be accepted. If an interim bill is submitted for services subject
to the TRICARE DRG-based payment system, it is to be denied. The
only exception to this is for certain qualifying outlier cases.
3.4.2.1 In order to qualify for interim
payments the following conditions must be met:
• The patient
has been in the hospital at least 60 days.
• Multiple claims for single
individuals must be submitted in chronological order.
If a condition is not met,
e.g., the claim is received out of chronological order, the claim
is to be denied.
3.4.2.2 A hospital may request additional
interim payments at intervals of at least 60 days after the date
of the first interim bill.
3.4.2.3 Contractors shall process the
initial claim as a complete claim and each subsequent claim as an
adjustment. However, the interim claims are only a method of facilitating
cash flow to providers, and the final bill is still the final accounting
on the hospital stay. Therefore, upon receipt of the final bill, the
contractor shall review the entire claim to ensure that it has been
correctly paid and shall ensure that the cost-share has been correctly
determined. See the TSM,
Chapter 2, Section 1.1, paragraph 7.0 for
TRICARE Encounter Data (TED) record submission requirements for
interim hospital billings.
3.5 Inpatient
Operating Costs
The TRICARE
DRG-based payment system provides a payment amount for inpatient
operating costs, including:
3.5.1 Operating
costs for routine services, such as the costs of room, board, therapy
services (physical, speech, etc.), and routine nursing services
as well as supplies (e.g., pacemakers) necessary for the treatment
of the patient;
3.5.2 Operating
costs for ancillary services, such as radiology and laboratory services
furnished to hospital inpatients (the professional component of
these services is not included and can be billed separately);
3.5.3 Take-home drugs for less than
$40;
3.5.4 Special care unit operating
costs (intensive care type unit services); and
3.5.5 Malpractice insurance costs
related to services furnished to inpatients.
3.6
Discharges
And Transfers
3.6.1
Discharges
Subject to the provisions of
paragraphs 3.6.2 and
3.6.3,
a hospital inpatient is considered discharged from a hospital paid
under the TRICARE DRG-based payment system when:
3.6.1.1 The patient is formally released
from the hospital; or
3.6.1.2 The patient dies in the hospital.
3.6.1.3 The patient is transferred
to a hospital or unit that is excluded from the TRICARE DRG-based payment
system under the provisions of
Section 4. Such
cases can be identified by Form Locator (FL) 17 on the Centers for
Medicare and Medicaid Services (CMS) 1450 UB-04 claim form and shall
be processed as a transfer, if the claim contains one of the qualifying
DRGs listed in
paragraph 3.6.4, and the patient is transferred
to one of the settings outlined in
paragraph 3.6.3.
3.6.2
Acute
Care Transfers
A discharge
of a hospital inpatient is considered to be a transfer for purposes
of payment under this subsection if the patient is readmitted the
same day (unless the readmission is unrelated to the initial discharge)
to another hospital that is:
3.6.2.1 Paid under the TRICARE DRG-based
payment system (such instances will result in two or more claims);
or
3.6.2.2 Excluded
from being paid under the TRICARE DRG-based payment system because
of participation in a statewide cost control program which is exempt
from the TRICARE DRG-based payment system under
Section 4 (such
instances will result in two or more claims); or
3.6.2.3 Authorized as a Designated
Provider (DP) [formerly Uniformed Services Treatment Facilities (USTFs)]
or a Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) hospital.
3.6.3
Post-Acute
Care Transfers
A discharge
of a hospital inpatient is considered to be a transfer for purposes
of this subsection when the patient’s discharge is assigned to one
of the qualifying DRGs listed in
paragraph 3.6.4, and the discharge is made
under any of the following circumstances:
3.6.3.1 To a hospital or distinct part
hospital unit excluded from the TRICARE DRG-based payment system
as described in
Section 4. Claims shall be coded 05, 62, 63,
85, 90, or 91 in FL 17 on the CMS 1450 UB-04 claim form. Effective
April 1, 2004, claims shall be coded 65 or 93 in FL 17 for psychiatric
hospitals and units.
3.6.3.2 To a Skilled Nursing Facility
(SNF). Claims shall be coded 03 or 83 in FL 17 on the CMS 1450 UB-04
claim form.
3.6.3.3 To home under a written Plan
Of Care (POC) for the provision of home health services from a home
health agency and those services begin within three days after the
date of discharge. Claims shall be coded 06 or 86 in FL 17 on the
CMS 1450 UB-04 claim form. Claims coded 06 or 86 with a condition
code of 42 or 43 in FL 18 shall be processed as a discharge instead
of a transfer.
3.6.3.4 Excluded from being paid under
the TRICARE DRG-based payment system as a Critical Access Hospital
(CAH) effective December 1, 2009.
3.6.3.5 To hospice care. Claims should
be coded 50 or 51 in FL 17 effective October 1, 2018.
3.6.4
Qualifying
DRGs
The qualifying
DRGs, for purposes of
paragraph 3.6.3, are listed on either the
TRICARE DRG web site at
http://www.health.mil/rates or
listed in the applicable addendum for the respective fiscal year.
Addendum C reflects the current fiscal year and the two most recent
fiscal years.
3.6.6 Payment For Transfers
3.6.6.1 General Rule. Except as provided
in
paragraphs 3.6.6.2 and a hospital that transfers
an inpatient under circumstances described in
paragraphs 3.6.2 or
3.6.3,
is paid a graduated per diem rate for each day of the patient’s
stay in that hospital, not to exceed the TRICARE DRG-based payment amount
that would have been paid if the patient had been discharged to
another setting. The per diem rate is determined by dividing the
appropriate DRG rate by the geometric mean LOS for the specific DRG
to which the case is assigned. Payment is graduated by paying twice
the per diem amount for the first day of the stay, and the per diem
amount for each subsequent day, up to the full DRG amount. For neonatal
claims, other than normal newborns, payment is graduated by paying
twice the per diem amount for the first day of the stay, and 125%
of the per diem rate for each subsequent day, up to the full DRG
amount.
3.6.6.2 Special
rule for DRGs meeting specific criteria. A hospital that transfers
an inpatient under the circumstances described in
paragraph 3.6.3 and the transfer
is assigned to a DRG subject to the special rule for transfers as
listed in Addendum C with a “Yes” in the POST ACUTE column and a
“Yes” in the SPEC PAY column, shall be paid under the provisions
of
paragraphs 3.6.6.2.1 and
3.6.6.2.2. Addendum
C reflects the current fiscal year and the two most recent fiscal
years.
3.6.6.2.1 Fifty
percent (50%) of the DRG-based payment amount plus one-half of the
per diem payment for the DRG for day one (one-half the usual transfer
payment of double the per diem for day one).
3.6.6.2.2 Fifty
percent (50%) of the per diem for each subsequent day up to the
full DRG payment.
3.6.6.3 Outliers.
• A
transferring hospital may qualify for an additional payment for
extraordinary cases that meet the criteria for cost outliers as
described in
Section 8, paragraph 3.2.6.1. When calculating
the cost outlier payment, if the LOS exceeds the geometric mean
LOS, the cost outlier threshold shall be limited to the DRG-based
payment plus the fixed loss amount. The contractor shall readjudicate
claims affected by this change if brought to their attention by
any source.
• Refer to
http://www.health.mil/rates for
payment details associated with outliers.
3.6.6.4 Transfer
assigned to DRG 601. If a transfer is classified into DRG 601 (Neonate,
transferred < 5 days old), the transferring hospital is paid
in full. DRGs for these descriptions can be found at
http://www.health.mil/rates.
3.7 Leave Of Absence Days
3.7.1 General. Normally, a patient
will leave a hospital which is subject to the DRG-based payment
system only as a result of a discharge or a transfer. However, there
are some circumstances where a patient is admitted for care, and
for some reason is sent home temporarily before that care is completed.
Hospitals may place patients on a leave of absence when readmission
is expected and the patient does not require a hospital level of
care during the interim period. Examples of such situations include,
but are not limited to:
• Situations
where surgery could not be scheduled immediately;
• A specific
surgical team was not available;
• Bilateral
surgery was planned;
• Further
treatment is indicated following diagnostic tests but cannot begin immediately;
• A change
in the patient’s condition requires that scheduled surgery be delayed
for a short time; or
• Test results
to confirm the need for surgery are delayed.
3.7.2 Billing for leave of absence
days. In billing for inpatient stays which include a leave of absence,
hospitals are to use the actual admission and discharge dates and
are to identify all leave of absence days by using revenue code
18X for such days. Contractors shall disallow all leave of absence days.
A leave of absence will be counted as a covered inpatient day (i.e.,
not disallowed as a leave of absence day) if the patient returns
to the facility by midnight of the same day. Neither the Program
nor the beneficiary may be billed for days of leave.
3.7.3 DRG-based payments for stays
including leave of absence days. Placing a patient on a leave of
absence will not result in two DRG-based payments, nor can any payment
be made for leave of absence days. Only one claim is to be submitted
when the patient is formally discharged (as opposed to being placed
on leave of absence), and only one DRG-based payment is to be made.
The contractor shall ensure that the leave of absence does not result
in long-stay outlier days being paid and that it does not increase
the beneficiary’s cost-share.
3.7.4 Services
received while on leave of absence. The technical component of laboratory
tests obtained while on a leave of absence is included in the DRG-based
payment to the hospital. The professional component shall be cost-shared
as inpatient. Tests performed in a physician’s office or independent
laboratory are also included in the DRG-based payment.
3.7.5 Patient dies while on leave
of absence. If patient should die while on leave of absence, the date
the patient left the hospital shall be treated as the date of discharge.
3.8 Area Wage Indexes
The
labor-related portion of the ASA will be adjusted to account for
the differences in wages among geographic areas and will correspond
to the labor market areas used in the Medicare PPS, and the actual
indexes used will be those used in the Medicare PPS. The wage index
used is to be the one for the hospital’s actual address--not for
the hospital’s billing address.
3.9 Redesignation
Of Certain Hospitals To Other Wage Index Areas
The TRICARE Program follows
this statutory requirement for the Medicare Prospective Payment System
(PPS), and the CMS determines the areas affected and wage indexes
used.
3.9.1 A
hospital located in a rural county adjacent to one or more urban
areas shall be treated as being located in the urban area to which
the greatest number of workers commute. The area wage index for
the urban area shall be used for the rural county.
3.9.2 In
order to correct inequities resulting from application of the rules
in
paragraph 3.9.1, CMS modified the rules for
those rural hospitals deemed to be urban. The TRICARE Program has
also adopted these changes. Some of these hospitals continue to
use the urban area wage index, others use a wage index computed
specifically for the rural county, and others use the statewide
rural wage index.
3.9.3 Public
Law 101-239 created the Medicare Geographic Classification Review
Board (MGCRB) to reclassify individual hospitals to different wage
index areas based on requests from the hospitals. These reclassifications
are intended to eliminate the continuing inequities caused by the reclassification
actions described in
paragraphs 3.9.1 and
3.9.2. The TRICARE
Program has adopted these hospital-specific reclassifications.
3.9.4 The wage index for an urban
hospital may not be lower than the statewide area rural wage index.