1 tma ubo cy 2007 oib rate package release presented by ubo project support team june 19 th : 0800,...

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TMA UBO CY 2007 OIB Rate Package Release

Presented by UBO Project Support Team

June 19th: 0800, 1400 & 2100 EDTJune 21st: 0800 & 1400 EDT

Dial in: (866) 866-2244Participant code: 7486926

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Agenda• CMAC• CMAC Component Rates• Associated Rate Tables (MEPRS Based

Rates)• Mapping Table Updates• Pharmacy Rates• Questions

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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”)

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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

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CMAC ED Rates Compare

CPT Code ’06 rate ’07 rate % change99281 $ 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)%

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CMAC Component Rate File

Added PET Scan for professional, technical and global ratesCPT code Professional Technical Global78608 $ 213.66 $ 641.57 $ 855.4378609 $ 213.66 $ 641.57 $ 855.4378459 $ 219.27 $ 511.97 $ 731.2478491 $ 219.27 $ 511.97 $ 731.2478492 $ 219.27 $ 511.97 $ 731.2478811 $ 85.54 $ 769.89 $ 855.4378812 $ 85.54 $ 769.89 $ 855.4378813 $ 85.54 $ 769.89 $ 855.4378814 $ 95.00 $ 855.00 $ 950.0078815 $ 95.00 $ 855.00 $ 950.0078816 $ 95.00 $ 855.00 $ 950.00

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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

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Ambulance Rate – Price Compare

CPT code ’06 rate ’07 rate % change

A0999FOR: $ 154.00 $ 170.00 10%IOR: $ 146.00 $ 161.00 10%IMET: $ 87.00 $ 99.00 14%

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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%

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APV Rate – Price Compare

CPT code ’06 rate ’07 rate % change

99199FOR: $ 1,299.00 $ 1,443.00 11%IOR: $ 1,231.00 $ 1,363.00 11%IMET: $ 729.00 $ 840.00 15%

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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%

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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

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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)

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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%

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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

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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

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Mapping Table Updates

• TPOCS Mapping Table• CPT Revenue Mapping Table• Modifier Mapping Table• DMIS ID Mapping Table

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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

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CPT Revenue Mapping Table

• Added 280 new CPT codes• Deleted 112 CPT codes• Added 387 new HCPCS codes • Deleted 124 HCPCS codes

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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)

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TMAUniformBusinessOffice DMIS ID Mapping Table

• Mapped all OCONUS sites to “391”• Mapped all 5400 sites to locality “000”

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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???

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TMA UBO Pharmacy Rates Update

Presented by the UBO Support Team

June 2007

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Pharmacy Rates Update

• Pharmacy rate file submitted to CITPO and RITPO (66,654 drugs)

• Effective June 30, 2007

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TMAUniformBusinessOffice 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

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Unit Measure Price Comparison

Rate File Simple Average Unit Measure Price (All NDCs in MCPF)

Existing (August 2006 release) UBO Pharmacy rate release (median GSN price)

$18.84

Updated July 2007 Pharmacy rate release (median AWP price)

$18.98 0.7%

Unit Measure Price Comparison- Existing Rate to Updated Rate (Top 100 GSNs)

10.01%

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Unit Measure Price: Market Comparison

Rate File Simple Average Unit Measure Price

Updated July 2007 rate release (Median AWP, Top 100 prescribed NDCs)

$3.47

Costco.com (Top 100 MHS prescribed NDCs)

$3.21

CVS.com (Top 100 MHS prescribed NDCs)

$3.98

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TMAUniformBusinessOffice 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

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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

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Questions

• Questions?