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Agenda

TMA UBO CY 2007 OIB Rate Package Release Presented by UBO Project Support Team June 19 th : 0800, 1400 & 2100 EDT June 21 st : 0800 & 1400 EDT Dial in: (866) 866-2244 Participant code: 7486926. Agenda. CMAC CMAC Component Rates Associated Rate Tables (MEPRS Based Rates)

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Agenda

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  1. TMA UBO CY 2007 OIB Rate Package ReleasePresented by UBO Project Support TeamJune 19th: 0800, 1400 & 2100 EDTJune 21st: 0800 & 1400 EDTDial in: (866) 866-2244 Participant code: 7486926 1

  2. Agenda • CMAC • CMAC Component Rates • Associated Rate Tables (MEPRS Based Rates) • Mapping Table Updates • Pharmacy Rates • Questions 2

  3. CMAC Rates - Overview • CMAC 391 locality is new – for OCONUS • Added rate for CPT code 90649 “HPV” ($100.00) • Added 171 Govt “no-pay” codes to the file • Added 90 lab/pathology codes/rates • Removed PET Scan codes (moved them to the CMAC Component file) • Removed Telephone Consult codes and rates (99371, 99372, 99373) • Set 40 codes to $0.00 (not available for separate reimbursement – considered part of the “global procedure”) 3

  4. CMAC Emergency Dept (ED) rates • 99281-99285 will only be used for the institutional portion of an ED encounter • Mapped to the UB 04 • Rates are based on 2007 CMS APC rates • Rather than the rates provided in the TMA CMAC files • Because of electronic billing requirements (e.g., 837i and 837p), the professional portion of the ED encounter will not be billed • Previously we combined the TMA CMAC file rate with the APC rate to obtain a single combined institutional and professional rate 4

  5. CMAC ED Rates Compare • CPT Code’06 rate’07 rate% change • 99281 $ 89.25 $ 50.01 (44)% • 99282 $ 99.77 $ 82.96 (17)% • 99283 $ 188.67 $ 130.00 (31)% • 99284 $ 317.74 $ 209.99 (34)% • 99285 $ 370.39 $ 325.25 (12)% 5

  6. CMAC Component Rate File • Added PET Scan for professional, technical and global rates • CPT codeProfessionalTechnicalGlobal • 78608 $ 213.66 $ 641.57 $ 855.43 • 78609 $ 213.66 $ 641.57 $ 855.43 • 78459 $ 219.27 $ 511.97 $ 731.24 • 78491 $ 219.27 $ 511.97 $ 731.24 • 78492 $ 219.27 $ 511.97 $ 731.24 • 78811 $ 85.54 $ 769.89 $ 855.43 • 78812 $ 85.54 $ 769.89 $ 855.43 • 78813 $ 85.54 $ 769.89 $ 855.43 • 78814 $ 95.00 $ 855.00 $ 950.00 • 78815 $ 95.00 $ 855.00 $ 950.00 • 78816 $ 95.00 $ 855.00 $ 950.00 6

  7. Associated Rate Tables • Ambulance • Anesthesia • APV (Ambulatory Procedure Visit) • Dental • Durable Medical Equipment/Supplies (DME/DMS) • IOR/IMET (Government Discount %) • Immunization • Observation • Pharmacy Dispensing Fee 7

  8. Ambulance Rate –Price Compare CPT code’06 rate’07 rate% change A0999 FOR: $ 154.00 $ 170.00 10% IOR: $ 146.00 $ 161.00 10% IMET: $ 87.00 $ 99.00 14% 8

  9. Anesthesia Rate –Price Compare ’06 rate’07 rate% change FOR: $ 795.00 $ 886.00 11% IOR: $ 752.00 $ 837.00 11% IMET: $ 476.00 $ 533.00 12% 9

  10. APV Rate – Price Compare CPT code’06 rate’07 rate% change 99199 FOR: $ 1,299.00 $ 1,443.00 11% IOR: $ 1,231.00 $ 1,363.00 11% IMET: $ 729.00 $ 840.00 15% 10

  11. Dental Rate – Price Compare CDT codes’06 rate’07 rate% change FOR: $ 100.00 $ 96.00 (4)% IOR: $ 95.00 $ 91.00 (4)% IMET: $ 40.00 $ 43.00 8% 11

  12. DME/DMS Rates • Continue to use CMS DME “floor rate” • No major price variances from 2006 to 2007 • Used January 2007 Rate file (most recent posted on CMS) • Removed “duplicate” codes and secondary modifiers to adhere to CHCS and TPOCS file specs 12

  13. IOR/IMET Discount % Compare Govt Discount’06’07% change IOR: 95% 95% 0% IMET: 56% 58% 4% Note: The government billing discount is applied to the Full Outpatient Rate (FOR) 13

  14. Immunization Rate –Price Compare ’06 rate’07 rate% change FOR: $ 47.00 $ 48.00 2% IOR: $ 44.00 $ 45.00 2% IMET: $ 26.00 $ 28.00 8% 14

  15. Observation Rate –Price Compare CPT code’06 rate’07 rate% change 99218: $ 520.33 $ 689.44* 33% 99219: $ 643.04 $ 819.94* 28% 99220: $ 790.32 $ 923.00* 17% * Institutional component only 15

  16. Pharmacy Dispensing Fee • 2007 Pharmacy Dispensing Fee calculated from MEPRS data at $9.00 • However, the move to Average Wholesale Price (AWP) includes pharmacy operations costs • Therefore, 2007 Pharmacy Dispensing Fee is set to $ 0.00 • More information on this will be covered in “Pharmacy” slides 16

  17. Mapping Table Updates • TPOCS Mapping Table • CPT Revenue Mapping Table • Modifier Mapping Table • DMIS ID Mapping Table 17

  18. TPOCS Mapping Table • Added all G codes, Q codes, and P codes • G codes mapped to CMAC rates and 1500 • Q codes mapped to CMAC rates and 1500 • P codes mapped to CMAC rates and UB-04 • Added the following modifiers: • 1P, 2P, 3P, 8P: Category II codes, G codes, P codes, and Q codes • 50 through 59: S codes • Approximately 108 ambulance Modifiers • Removed telephone consult codes 99371, 99372 & 99373 18

  19. CPT Revenue Mapping Table • Added 280 new CPT codes • Deleted 112 CPT codes • Added 387 new HCPCS codes • Deleted 124 HCPCS codes 19

  20. Modifier Mapping Table • Added 1P, 2P, 3P, 8P • Added Ambulance modifiers: (DE, DG, DH, DI, DJ, DP, DR, DS, DX, ED, EG, EH, EI, EJ, EN, EP, ER, ES, EX, GD, GE, GH, GI, GJ, GN, GP, GR, GS, GX, HD, HE, HG, HI, HJ, HN, HP, HR, HS, HX, ID, IE, IG, IH, IJ, IN, IP, IR, IS, IX, JD, JE, JH, JI, JN, JP, JR, JS, JX, ND, NE, NG, NH, NI, NJ, NP, NR, NS, NX, PD, PE, PG, PH, PI, PJ, PN, PR, PS, PX, RD, RE, RG, RH, RI, RJ, RN, RP, RD, RX, SD, SE, SG, SH, SI, SJ, SN, SP, SR, SX, XD, XE, XG, XH, XI, XJ, XN, XP, XR, XS) 20

  21. DMIS ID Mapping Table • Mapped all OCONUS sites to “391” • Mapped all 5400 sites to locality “000” 21

  22. Next Steps • CY 07 OIB Rate Package is in testing CITPO/RITPO • Dr. Casscells Letter is in “coordination” • Anticipate a 30 June 2007 effective date • Questions??? 22

  23. TMA UBO Pharmacy Rates Update Presented by the UBO Support Team June 2007 23

  24. Pharmacy Rates Update • Pharmacy rate file submitted to CITPO and RITPO (66,654 drugs) • Effective June 30, 2007 24

  25. Pharmacy Rates Update • Changes to pricing method for the July 2007 rate update • Use Median Average Wholesale Price (AWP) • No dispensing fee • Delete OTC drugs from rate file • Delete Miscellaneous supplies from rate file 25

  26. Unit Measure Price Comparison 26

  27. Unit Measure Price: Market Comparison 27

  28. Coordination Activities • February 2007 Quarterly UBO Advisory Working Group • RADM McGinnis and Pharmacy Board of Governors - March 30, 2007 • Resource Management Steering Committee - April 19, 2007 • Deputy SGs - Chief Financial Officer Integration Council - April 25, 2007 • UBO Newsletter Articles 28

  29. Coordination Activities (Continued) • Continued Coordination • Rate briefing teleconferences • Pharmacy Pricing Estimator Tool (P-PET) • Brief Department of Defense Education Activity (DoDEA) • Reminder: It is the responsibility of local MTFs to communicate rate changes to their pay patients 29

  30. Questions • Questions? 30

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