UBO/UBU Conference - TPOCS - 22-25 March 2010
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Billing Data Issues Revenue Codes Incorrect Billing Data - Pharmacy Codes and Rates Missing or Incorrect NPI PowerPoint PPT Presentation


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Current TPOCS Helpdesk Issues. Billing Data Issues Revenue Codes Incorrect Billing Data - Pharmacy Codes and Rates Missing or Incorrect NPI. Current TPOCS Helpdesk Issues. Database Issues TPOCS Interface OHI Updates Provider Updates ICD-9-CM Diagnosis Codes.

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Billing Data Issues Revenue Codes Incorrect Billing Data - Pharmacy Codes and Rates Missing or Incorrect NPI

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Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Current TPOCS Helpdesk Issues

  • Billing Data Issues

  • Revenue Codes

  • Incorrect Billing Data - Pharmacy

  • Codes and Rates

  • Missing or Incorrect NPI

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Current TPOCS Helpdesk Issues

  • Database Issues

  • TPOCS Interface

  • OHI Updates

  • Provider Updates

  • ICD-9-CM Diagnosis Codes

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Current TPOCS Helpdesk Issues

  • Accounting Issues

  • Account is not in GL

  • Account Closed is in GL and Open in Patient Summary

  • TPOCS Report Issue

  • General Ledger reports do not balance in TPOCS

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Revenue Codes

  • Incorrect or Missing Revenue Code

  • RC-250 for J-Codes

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Incorrect Billing Data

  • Incorrect Units of Service

  • Incorrect Dispense Quantities

  • Incorrect Rate Assigned

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Incorrect Billing Units or Quantities

  • Dispensing Unit Different from Billing Unit

  • Mismatch Units in CHCS/PDTS and TPOCS

  • TPOCS Calculations for Pharmacy Billing

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

Incorrect Billing Units or Quantities

Pharmacy Fill Order from CHCS for Prescription # BX5174819

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

Incorrect Billing Units or Quantities

  • Encounter Data

  • NDC No. - 00025141160 (Arthrotec 50 Table EC)

  • Qty - 180

  • Days Sup - 90

  • TPOCS Est. Charges

  • TPOCS Cost per unit - $1.81

  • Total Line Item Charges - $ 325.80

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

Incorrect Billing Units or Quantities

Data from CHCS to TPOCS - PHARM Datfile

Encounter Data string:

(30)^0067^P^N^(152107)^52^A31^117^^^^09063004230^063020090824^124862^0306^FCCA^(BX5174819)^1^(1080000)^(90)^(00025141160)^N^A^188^06302009^^^0069^0069^2125804^1801958806^2

  • File Rec No.- 30

  • Patient IEN- 152107

  • RX No. - BX5174819

  • Qty - 108000

  • Days Sup- 90

  • NDC No.- 00025141160

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

Incorrect Billing Units or Quantities

  • NDC No. - 00025141160 (Arthrotec 50 Table EC)

  • Qty - 108000

  • Days Sup - 90

  • TPOCS Cost per unit - $1.81

  • Total Line Item Charges - ?

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Codes and Rates

  • Incorrect or No Rate for CPT-4 Code

  • NDC not in TPOCS

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Issues: Incorrect or No CPT-4 Code and/or Rate in TPOCS

  • Missing or Expired CPT-4 Code

  • CPT-4 Code Has No Rate in TPOCS

  • Incorrect Rate Populated on TPOCS Bill

  • Cannot Change Rate on TPOCS Bill

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Issues: NDC not in TPOCS

  • Missing, obsolete or inactive NDC numbers in TPOCS

  • NDC in CHCS and not in TPOCS

  • No rate for NDC in TPOCS

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • National Provider ID - NPI

  • Missing or Incorrect NPI Data

  • Database

  • TPOCS Interface

  • Provider Data

  • DoD Extender Codes

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Issues: Missing or Incorrect NPI Data

  • NPI Type 1 - Provider NPI

  • Physician/Provider Does Not have a NPI in TPOCS

  • NPI Type 2 - Facility NPI

  • Treating Facilities without NPI’s in TPOCS

  • Incorrect Facility NPI Type 2

  • DMIS ID with No Associated Facility NPI

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Issue: Provider NPI Type 1 not in TPOCS

  • Only Physicians with a Provider Class of 01 will be assigned an NPI

  • Individuals with a Provider Class of 04 will not have a NPI in TPOCS

  • Provider NPI’s can be manually entered in TPOCS when processing encounters.

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Facility NPIs are related to site DMIS ID’s

  • Three (3) Types of Facility or NPI Type 2:

    • Treating Facility NPI- site associated with care or treatment

    • Billing Facility NPI- site submitting the claim

    • Pharmacy NPI- site Pharmacy/Dispensing facility

    • NOTE:Pharmacies do not have DMIS ID’s

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Billing Data Issues

  • Issue: Missing or incorrect Facility NPI

  • Satellite site(s) attached to a host facility may not have a NPI Type 2(Facility) assigned.

  • Cannot generate claims without site NPI.

  • Cannot enter missing NPI into claim or TPOCS database.

    • Pharmacies do not have DMIS ID’s

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issues

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issues

  • TPOCS Interface

  • Daily CHCS files are not loading in TPOCS

  • OHI Data not populating or updating in TPOCS

  • Provider Data

  • Provider Not in TPOCS

  • Invalid Provider Taxonomy Code

  • DoD Extender Codes

  • DoD Extender Codes for ICD-9-CM Codes

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - TPOCS Interface

  • Issue: Daily CHCS files are not loading in TPOCS

  • Signs and Symptoms:

  • No encounters loaded for that day in TPOCS

  • Did not see all of the expected encounters in TPOCS

  • Did not get any Clinic or Lab/Rad or Pharmacy encounters in TPOCS

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - TPOCS Interface

  • Issue: Daily CHCS files are not loading in TPOCS

  • Most Common Reasons:

  • TPOCS Interface Loader in not Turned-on

  • CHCS provided the incorrect file extension for the data file

  • CHCS did not send over the required (six) 6 daily files (5 out of 6)

  • Trailer record in missing from any one of the data files

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - TPOCS Interface

Three (3) Types of Other Health Insurance (OHI)

Files:

  • DOHI - Daily OHI

  • SOHI - Supplemental OHI

  • IOHI - Initialization OHI

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - TPOCS Interface

  • There are two (2) types of OHIrecords in OHI ASCII files.

  • The OHI Record Type is determined by the type of data which was added or modified during the 24-hour collection period.

  • The two (2) Record Types are “O” records and “D” records.

  • Record Type - O (Other Health Insurance)

  • Record Type - D (Patient Demographics)

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - TPOCS Interface

  • Issue: OHI Data not populating or updating in TPOCS

    Most Common Reasons:

  • Patient has multiples of the same policy in TPOCS

  • Patient and/or Policy Link has been broken in CHCS

  • Patient Policy is inactive in TPOCS

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - TPOCS Interface

Update OHI in the TPOCS database

There are two (2) additional CHCS files that can

be provided that will update the TPOCS OHI

database:

  • Supplemental OHI ASCII File (SOHI)

  • Initialization OHI ASCII File (IOHI)

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issues

  • Issue: Referring Provider data not in TPOCS

  • (Required for CMS-1500 e-billing)

  • Mainly electronic billing requirement (837p)

  • Referring Provider data comes from CHCS and does not appear in the TPOCS billing screen (SCR submitted)

  • Referring Provider data cannot be entered in TPOCS

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - Provider Data

  • Issue: Provider Not in TPOCS

  • Missing or Invalid data in the Provider file (DPROV) from CHCS

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - Provider Data

  • Daily Provider ASCII File (DPROV)

  • TPOCS provider data is updated from CHCS. The DPROV

  • file contains all of the provider data information from CHCS.

  • The Daily Provider File - DPROV updates based on:

  • When a new record is added

  • When existing record is edited

  • When the Provider file is ‘initialized’ through a user menu option, for OIB

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - Provider Data

  • CHCS Provider Criteria:

  • Providers must be DBA Active (field 13)

  • If the Primary Provider Taxonomy is recorded, then include it in the Provider ASCII file.

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - Provider Data

  • Issue: Invalid Provider Taxonomy Code

  • Provider Taxonomy Codes currently not in TPOCS:

  • 1710I1002X - Corpsman, Independent Duty

  • 1710I1003X - Technical, Independent Duty Medical

  • 390200000X - Resident/Intern w/o License

  • http://www.wpc-edi.com/codes/taxonomy

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - Provider Data

  • Issue: Invalid Provider Taxonomy Code

    Database Problems:

  • Provider(s) do not load in the TPOCS database

  • Provider(s) can be identified on the TPOCS File Upload Report

  • Data associated with the provider(s) do not populate into TPOCS

  • Encounters that list the provider as the primary HCP must be identified and manually entered in TPOCS to create claims.

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - Provider Data

  • Issue: Provider Not in TPOCS

  • Due To: Missing or Invalid data in the Provider file (DPROV) from CHCS:

  • Which Could Be:

  • Provider is Not DBA Active in CHCS

  • Provider Taxonomy Code - (Missing/Invalid)

  • Provider Specialty Code - (Missing/Invalid)

  • EDI_PN as a placeholder - (Missing/Invalid)

    Identified: TPOCS File Upload Report

    Corrected:CHCS

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Database Issue - DoD Extender Codes

  • Issue: DoD Extender Codes for ICD-9-CM codes

  • TPOCS rejects ICD-9-CM Codes with more than six (6) characters for the Diagnosis Field. (123.56 01)

  • CHCS currently sending more than six (6) characters for this data field.

  • Encounters associated with those rejected ICD-9-CM as the primary diagnosis will not load in TPOCS.

  • Cannot use on claims (paper/electronic)

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Accounting Issues

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Accounting Issues

  • Issue: General Ledger reports do not balance in TPOCS

  • TPOCS General Ledger Reports are not designed to balance TPOCS.

  • Not all reports in TPOCS balance the other

  • There are reports in TPOCS that assist with balancing

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

Accounting Issues

  • Issue: GL Reports Do Not Balance DD2570

  • The DD2570 does not balance with the other reports in TPOCS such as the; Activity Reports, Accounts Receivable Reports, and Break Out Reportsin TPOCS that provide the same or similar financial data.

    Reports use different criteria is:

  • DD2570 - Date of Encounter or DOS

  • TPOCS Reports - Date of Last Transaction(s)

UBO/UBU Conference - TPOCS - 22-25 March 2010


Billing data issues revenue codes incorrect billing data pharmacy codes and rates missing or incorrect npi

??? Questions ???

UBO/UBU Conference - TPOCS - 30 March - 2 April 2009


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