1 new inpatient billing guidance for inpatient services provided under va/dod health care resource...

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New Inpatient Billing Guidance

For Inpatient Services Provided Under VA/DoD Health

Care Resource Sharing Agreements Presented by the

UBO Support Team

Dial in: 1-866-866-2244 Conf code: 1782483#

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Objectives

• Understand new Billing Guidance for inpatient care provided under VA/DoD Health Care Resource Sharing Agreements

• Understand where to find, and how to use the Modified TRICARE DRG Payment Calculator to calculate payment due for hospitalization

• Understand how to look-up Area Wage Index Number for a hospital (an input to the payment calculator)

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BackgroundVA/DoD Health Care Resource

Sharing Policy Guidance

• VA/DoD Policy Guidance– Use CHAMPUS Maximum Allowable Charge rates, less a 10

percent discount, for institutional and professional charges– Apply to nearly all clinical services and specialties

• Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), and Blind Rehab cases will not fall under this methodology

– Apply to all inpatient sharing agreements, including joint ventures

– Allow for additional payment for cases which involve outlier days (i.e., Long-Stay cases)

– Do not bill for costs associated with Graduate Medical Education or Capital Expense Equipment

– Apply to existing and new VA/DoD Sharing Agreements

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Implementation forInpatient Billing

• Use Diagnosis Related Groups (DRG) payment approach for Institutional (hospitalization) portion of inpatient care– Use Modified TRICARE DRG Payment Calculator

to calculate amount to be billed

• Use Healthcare Common Procedure Coding System (HCPCS) for Non-Institutional (professional and other services) not included in DRG-based payment

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Implementation in the VA and DoD

• VA expects to incorporate this billing approach into their current information systems

• DoD will proceed initially with manual billing, and incorporate this billing approach into its Chargemaster-Based Billing System (CMBB)

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Implementation forInstitutional Services

• Use Diagnosis Related Groups (DRG) payment approach for Institutional (hospitalization) portion of inpatient care– Use Modified TRICARE DRG Payment

Calculator to calculate amount to be billed

• Modified TRICARE DRG Payment Calculator and associated billing guidance will be posted on the UBO web site

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Data Sources and Flows

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CodedInpatient

Case

• DRG Number• Length of Stay (LOS)• Disposition Status Code

• Area Wage Index Number

(Look-up table with Calculator)

ModifiedTRICARE

DRG PaymentCalculator

Billable AmountFor Institutional Care

(10% VA/DoD discount applied)

Use in your Current VA/DoD

SharingAgreement

BillingProcess

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Modified TRICARE DRGPayment Calculator

• Inputs– DRG– Length of Stay (LOS)– Disposition Status (Code)– Area Wage Index Number– VA/DoD Resource Sharing Policy parameters

• Output– Amount to be billed, with 10% discount already

calculated

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• VA/DoD Resource Sharing Policy parameters– Use TRICARE/CHAMPUS approach to

Institutional payment by Diagnosis Related Groups (DRGs)

– Use a partial per diem marginal cost factor for cases with very long length of stay

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Modified TRICAREDRG Payment Calculator (an MS Excel Workbook)

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Look-up Table of Area Wage Index

NumbersBy Zip Code

ModifiedTRICARE DRG

CalculatorWorksheet

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Modified TRICAREDRG Payment Calculator

(an MS Excel Workbook)

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PaymentDetailsPortion

(For Info Only)

ModifiedTRICARE DRG

CalculatorPortion

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Modified TRICAREDRG Payment CalculatorOverview of Inputs & Output

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Case-specificinputs

Payment Calculation Portion of the Calculator

Hospital-specificinput

Case-specificoutput

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Modified TRICAREDRG Payment CalculatorOverview of Inputs & Output

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Case-specificoutput

VA/DoD ResourceSharing PolicyInformation

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• Case-specific inputs– Diagnosis Related Group (DRG) Number– Length of Stay (LOS)– Disposition Status (Code)

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Case-specific Inputs

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Case-specificinputs


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Modified TRICAREDRG Payment CalculatorPopulation of DRG Description

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DRG DescriptionPopulated

Automatically


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• Hospital-specific input is the Area Wage-Index number– Applied for the physical location (i.e., zip code) of

the hospital which treats the patient– Adjusts the Labor portion of the payment amount

to the level of local wages for the hospital location– Is a constant number for each fiscal year for a

given hospital– A Zip_2_Wage look-up table is provided as part of

the Modified TRICARE DRG Payment Calculator workbook

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Modified TRICAREDRG Payment Calculator (Zip_2_Wage Look-up Table)

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Table ofArea Wage

Index Numbers

By Zip Code

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Modified TRICAREDRG Payment Calculator (Zip_2_Wage Look-up Table)

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Area Wage Index Look-

upTable

By Zip Code

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Modified TRICAREDRG Payment Calculator Using the Zip_2_Wage Index Look-Up Table

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Area Wage Index

Number

Zip CodeOf Treating

Hospital

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• Hospital-specific input– Area Wage Index Number

• Look-up in Zip_2_Wage Look-up Table, if necessary, based on zip code of treating hospital

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Hospital-specific Input

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Hospital-specificinput

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Payment Policy Information

• Payment policy summary – National Adjusted Standardized Amount

(ASA) is a constant for each fiscal year– ASA split between Labor and Non-Labor

adjusted based on Area Wage Index– VA/DoD Resource Sharing Discount = 10%– Long-Stay marginal cost factor = 33% of

calculated per diem amount

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Modified TRICAREDRG Payment CalculatorReading the Billable Amount

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VA/DoD ResourceSharing PolicyInformation

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• Amount to be billed is automatically calculated using the following:– VA/DoD Resource Sharing policy

information– Case-specific inputs, and – Hospital-specific input

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Modified TRICAREDRG Payment CalculatorReading the Billable Amount

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Case-specificoutput

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Payment Details• The calculator provides details of the

payment calculations as they apply to inpatient case types– Statistical Inlier DRG– Short-Stay– Long-Stay– Transfer

• For information only; not used in billing

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Payment Details Portion of the Calculator(Not used in billing process. Provided as information only)

Details ofInformation

Used inPayment

calculations

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Summary

• New VA/DoD policy memorandum describes Inpatient Billing Guidelines for inpatient care provided under VA/DoD Health Care Resource Sharing agreements

• Modified TRICARE DRG Payment Calculators will calculate of amount to be billed for Institutional component of service– FY2006 version completed; FY2007 version in

development• Calculators and billing guidance will be

posted on the UBO web site

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Quiz Questions

• What is the basis for payment of inpatient Institutional care under the new VA/DoD Inpatient Billing Guidelines for care provided under VA/DoD Health Care Resource Sharing Agreements?

• How will users find the correct Area Wage Index Number to use in the payment calculator?

• Where will the payment calculators and implementation guidance be posted?

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Questions?

• Please continue to use the MHS Helpdesk, the TMA UBO Helpdesk, and/or contact us directly: (703) 575-5385 or at [email protected]

• Please remember the TMA UBO website, it has a lot of information available

• Please continue to report code/rate/mapping issues: fix now and/or take into consideration for next rate update

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VA/DoD Inpatient BillingGuidance

Back-Up Materials

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Disposition Status Codes01= Home, self-care02= Short term hospital03= Skilled Nursing Facility (SNF)04= Intermediate Care Facility (ICF)05= Other facility06= Home Health Service07= Left Against Medical Advice (AMA)20= Died30= Still a Patient50= Hospice-Home51= Hospice-Medical Facility61= Swing Bed62= Rehab Facility/Rehab Unit63= Long Term Care Hospital65= Psychiatric Hospital or Unit66= Discharge/Transfer to Critical Access Hospital (CAH)71= OP Services - Other Facility72= OP Services - This Facility

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1 new inpatient billing guidance for inpatient services provided under va/dod health care resource...

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