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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Presentation Transcript

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


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


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

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


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

  • Incorrect Billing Data

  • Incorrect Units of Service

  • Incorrect Dispense Quantities

  • Incorrect Rate Assigned

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


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

Incorrect Billing Units or Quantities

Pharmacy Fill Order from CHCS for Prescription # BX5174819

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


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

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

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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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


Database Issues

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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


Accounting Issues

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


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


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


??? Questions ???

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


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