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 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 Locator (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.
3.3.4 The contractors
shall 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
The contractor shall maintain
at least three years of APC relative weights, payment rates, wage
indexes, etc., in their systems. 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. 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 (CPM), 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.