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.