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.