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Payment Calculator

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					  TMA
Uniform
Business
 Office



           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#
                                1
  TMA
Uniform
Business       Objectives
 Office


• 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)
                      2
                          Background
  TMA
Uniform
               VA/DoD Health Care Resource
Business
 Office
                  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

                                      3
  TMA
           Implementation for
Uniform
Business     Inpatient Billing
 Office


• 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
                        4
  TMA
           Implementation in the
Uniform
Business       VA and DoD
 Office


• 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)

                     5
  TMA
            Implementation for
Uniform
Business   Institutional Services
 Office


• 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
                        6
  TMA
Uniform
                       Data Sources
Business
 Office                 and Flows

                             Modified                      Billable Amount
      Coded
                            TRICARE                      For Institutional Care
     Inpatient
                           DRG Payment
       Case
                            Calculator                   (10% VA/DoD discount applied)
• DRG Number
• Length of Stay
  (LOS)                • Area Wage Index Number
• Disposition Status
  Code                 (Look-up table with Calculator)       Use in your
                                                            Current VA/DoD
                                                                Sharing
                                                              Agreement
                                                                 Billing
                                                                Process

                                         7
  TMA
Uniform
           Modified TRICARE DRG
Business
 Office     Payment 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
                          8
  TMA
Uniform
           Modified TRICARE DRG
Business
 Office     Payment Calculator
• 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


                       9
                  Modified TRICARE
       TMA
     Uniform
                DRG Payment Calculator
     Business
      Office     (an MS Excel Workbook)




   Modified
TRICARE DRG
  Calculator                         Look-up Table
  Worksheet                          of Area Wage
                                    Index Numbers
                                      By Zip Code


                          10
             Modified TRICARE
  TMA
Uniform    DRG Payment Calculator
Business
 Office      (an MS Excel Workbook)


                                         Modified
                                      TRICARE DRG
                                        Calculator
                                         Portion




                                         Payment
                                          Details
                                          Portion
                                      (For Info Only)


                      11
             Modified TRICARE
  TMA
Uniform    DRG Payment Calculator
Business
 Office    Overview of Inputs & Output
      Payment Calculation Portion of the Calculator

                                                 Case-
                                                specific
                                                 inputs



                                            Hospital-
                                            specific
                                             input




                                  Case-
                                 specific
                          12      output
             Modified TRICARE
  TMA
Uniform    DRG Payment Calculator
Business
 Office    Overview of Inputs & Output
      Payment Calculation Portion of the Calculator

                                                VA/DoD Resource
                                                 Sharing Policy
                                                   Information




                          13        Case-specific
                                       output
  TMA
Uniform
           Modified TRICARE DRG
Business
 Office     Payment Calculator
• Case-specific inputs
   – Diagnosis Related Group (DRG) Number
   – Length of Stay (LOS)
   – Disposition Status (Code)




                    14
             Modified TRICARE
  TMA
Uniform
           DRG Payment Calculator
Business
 Office      Case-specific Inputs
      Payment Calculation Portion of the Calculator

                                         Case-
                                        specific
                                         inputs




                          15
             Modified TRICARE
  TMA
Uniform    DRG Payment Calculator
Business
 Office    Population of DRG Description
      Payment Calculation Portion of the Calculator

                                       DRG Description
                                         Populated
                                        Automatically




                          16
  TMA
Uniform
           Modified TRICARE DRG
Business
 Office     Payment Calculator
• 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
                           17
             Modified TRICARE
  TMA
Uniform    DRG Payment Calculator
Business
 Office     (Zip_2_Wage Look-up Table)




                                      Table of
                                    Area Wage
                                  Index Numbers
                                    By Zip Code


                       18
             Modified TRICARE
  TMA
Uniform    DRG Payment Calculator
Business
 Office     (Zip_2_Wage Look-up Table)




                              Area Wage
                            Index Look-up
                                Table
                             By Zip Code




                       19
             Modified TRICARE
  TMA
Uniform    DRG Payment Calculator
Business
 Office    Using the Zip_2_Wage Index Look-Up Table




                             Area Wage
                               Index
                              Number



                             Zip Code
                            Of Treating
                             Hospital




                             20
  TMA
Uniform
             Modified TRICARE DRG
Business
 Office       Payment Calculator
• 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




                              21
             Modified TRICARE
  TMA
Uniform
           DRG Payment Calculator
Business
 Office      Hospital-specific Input
      Payment Calculation Portion of the Calculator




                                      Hospital-
                                      specific
                                       input




                          22
           Modified TRICARE DRG
  TMA
Uniform
Business
            Payment Calculator
 Office     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
                       23
             Modified TRICARE
  TMA
Uniform
           DRG Payment Calculator
Business
 Office    Reading the Billable Amount
      Payment Calculation Portion of the Calculator

                                         VA/DoD Resource
                                          Sharing Policy
                                            Information




                          24
  TMA
Uniform
           Modified TRICARE DRG
Business
 Office     Payment Calculator
• Amount to be billed is automatically
  calculated using the following:
   – VA/DoD Resource Sharing policy
     information
   – Case-specific inputs, and
   – Hospital-specific input



                     25
             Modified TRICARE
  TMA
Uniform
           DRG Payment Calculator
Business
 Office    Reading the Billable Amount
      Payment Calculation Portion of the Calculator




                          26        Case-specific
                                       output
  TMA
           Modified TRICARE DRG
Uniform
Business    Payment Calculator
 Office
                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
                        27
  TMA
              Modified TRICARE
Uniform
Business    DRG Payment Calculator
 Office


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




                                                                           Details of
                                                                          Information
                                                                            Used in
                                                                           Payment
                                                                          calculations




                                       28
  TMA
Uniform
Business         Summary
 Office


• 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
                        29
  TMA
Uniform
Business    Quiz Questions
 Office


• 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?
                       30
  TMA
Uniform
Business       Questions?
 Office


• Please continue to use the MHS Helpdesk,
  the TMA UBO Helpdesk, and/or contact us
  directly: (703) 575-5385 or at
  ubo.helpdesk@altarum.org
• 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
                       31
  TMA
Uniform
           VA/DoD Inpatient Billing
Business
 Office         Guidance




             Back-Up Materials



                     32
   TMA
 Uniform
               Modified TRICARE DRG
 Business
  Office        Payment Calculator
Disposition Status Codes
     01= Home, self-care
     02= Short term hospital
     03= Skilled Nursing Facility (SNF)
     04= Intermediate Care Facility (ICF)
     05= Other facility
     06= Home Health Service
     07= Left Against Medical Advice (AMA)
     20= Died
     30= Still a Patient
     50= Hospice-Home
     51= Hospice-Medical Facility
     61= Swing Bed
     62= Rehab Facility/Rehab Unit
     63= Long Term Care Hospital
     65= Psychiatric Hospital or Unit
     66= Discharge/Transfer to Critical Access Hospital (CAH)
     71= OP Services - Other Facility
     72= OP Services - This Facility

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