25_Attachment_J-15_DP_Codes.doc

Attachment J-15, DP Codes

Attachment J-15 DP Codes

DESIGNATED PROVIDER (DP) CODES

1.1 Management Clinical Data (MCD) - Medical/Clinical Encounter

1.1.1. MCD Description and Purpose

Encounter data will include the records for all services provided to each enrollee during the previous month. Earlier services provided are reported in the monthly submission, regardless of how much delay the DP experiences in collecting the information. For evaluation purposes, it is important to capture all care provided to enrollees. Incomplete data may impact capitation rates when they are recalibrated.

Reported services will cover all encounter settings, including hospital, related professional services for admitted patients and outpatient care – this includes all laboratory, mental health, and radiology services. This file will be uploaded through the web interface or submitted via the SFTP upload process by the 15th of each month (or as posted in the Annual DP Processing Calendar distributed by TMA).

Encounter summary and error reports will be posted on the TRICARE DP Portal and released via SFTP on or before the 20th of the month of submission.

1.1.2. MCD History

Encounter records will be retained for the length of the contract beginning 6/1/03.

1.1.3. MCD Submission Standards

Since MCD can be submitted as Hospital Services data, Inpatient Professional Services data, or Outpatient Professional Services data, the encounter setting field will indicate the type of care reported. A grid, to the right of the data elements, indicates which elements are used for the encounter setting reported. If the grid indicates the field is not reported for an encounter setting, the field should be left blank.

Encounters need to be submitted in a chronological order by processing time of the claim. This will ensure that all change and delete records will be processed correctly and with minimal processing errors.

UNIQUE KEY:

The unique key used to identify each MCD submission is DMIS ID and Unique Patient Reference Number.

TRANSACTION TYPE:

A single submitted record must contain exactly ONE of the following:

1. An “Initial” encounter record, transaction type “I”. If two initial records are submitted with the exact same information in ALL the fields then the second record will be rejected as a duplicate. Otherwise, if any fields are different the record will be treated as a change record. Submissions for I transactions need to accompany the "original" record with each and every F record that applies to it. NOTE: They need to follow the spec on the Unique Patient Reference Number, and NOT use a qualifier (adding an "A" or "B" to the end of the ID).

2. A “Change” encounter record, transaction type “C”. If a corresponding Initial record (matched by the unique key fields) is not found, the record will be processed as an “Initial” record. All fields on this type of record will be considered to be authoritative and not dependent on any previous submission as of the submission date and time.

Submissions for C transactions need to accompany the "original" record with each and every F record that applies to it. Please follow the spec on the Unique Patient Reference Number, and NOT use a qualifier (adding an "A" or "B" to the end of the ID).

3. An “Extension” encounter record, transaction type “F”. This type must follow an existing Initial or Change record and is matched to the Initial record by the unique key fields. This type is used to report additional services (beyond the initial six services). If a Change record is submitted for an Extension record, all corresponding Extension records must also be resubmitted.

4. A “Delete” encounter record, transaction type “D”. All non-key fields on this record will be ignored and all corresponding records, matched by the unique key fields, will be marked invalid in the warehouse. When it comes to deletions, do NOT send in the F records with the deleted record. Concept Plus will assume that the deleted I/C record includes the intentions to delete the related F records.

MATCH TO ENROLLMENT:

Patient ID and Sponsor SSN will be used to identify DEERS Family ID and DEERS Beneficiary ID on the enrollment master. If a successful match cannot be made, the record will be rejected. Concept Plus will retain the reported values for DEERS Family ID and Beneficiary ID as submitted on the claim. However, when reporting back to the DPs the ID’s matched from enrollment will be used. The match to Enrollment will also contain a match to DMIS with corresponding date logic, the earliest date of service must fall within the HCDP Policy Enrollment Begin and End Dates otherwise the claim will be rejected as not matching to enrollment. All co-pay information will also be submitted on a rejected and accepted claim to DEERS on the Cat Cap file. In order for a cat cap adjustment to take place a Delete or Adjustment record must be submitted for this original record (even if it was rejected).

MATCH TO PROVIDER:

The Unique Provider ID and DMIS ID of the Provider Entity will be used to identify the provider of the clinical encounter. The corresponding provider records are to be submitted on the monthly provider file.

DIAGNOSIS AND PROCEDURE CODE GUIDELINES:

When coding diagnosis(es) and procedure(s) for encounter data all codes must be the full complement of digits as required by the appropriate coding manuals (ICD-9-CM, CPT, and HCPCS). Revenue Center codes are not to be submitted except for a few valid Home Health Revenue Center Codes. These acceptable Revenue Center codes should be submitted in the Service 1-6 procedure code fields.

ICD-9-CM annually updates codes (new codes, revised texts, and/or revised code titles). These code changes are effective October 1 of each year. There will be a three (3) month “grace period” (October 1 through December 31) for these updates for dates of service October 1 through December 31. The grace period applies to claims received prior to January 1 2002 and subsequent contract years that include the updated codes for dates of service October 1 through December 31. During this time period the claims processors are to accept both the old and new codes. Claims received after January 1 of each year are to be returned by the claims processor. Each year Concept Plus will accept both the old and new codes through the January 15th clinical and pharmacy data submissions. After that submission, all clinical and pharmacy claims, with the old codes, will be placed in the pend file. Grace periods are only effective with the new contract that began June 1, 2001.

CPT and HCPCS annually update codes (additions, deletions and revisions). These code changes are effective January 1 of each year. There will be a three-month “grace period” (January 1 through March 31) for these updates for dates of service January 1 through March 31. The grace period applies to claims received prior to April 1 of 2002 and subsequent contract years that include the updated codes for dates of service January 1 through March 31. During this time period the claims processors are to accept both the old and new codes. Claims received after April 1 of each year are to be returned by the claims processor. Each year both the old and new codes will be accepted through the April 15th clinical and pharmacy data submissions. After that submission, all clinical and pharmacy claims with the old codes will be placed in the pend file. CPT and HCPCS may have periodic updates throughout the year. A three-month “grace period” will be based on the effective date or deletion date of the code.

1.1.4. MCD Error/Reject Handling

All records will be loaded to the warehouse, including all fatal/rejected records, except when a patient ID is not found. This is due to the fact that the co-payment amounts are still submitted to DEERS regardless if a record is rejected or not. Either a delete or corrected record will need to be submitted to the warehouse to fix the previous errors. A data warehouse processing status code will identify fatal records.

1.1.5. MCD Format (Input from DPs)

The DP will report all clinical services provided for all DP enrollees. This file format and data elements are required for each encounter setting (Hospital, Inpatient Professional or Outpatient Professional services) when reporting the monthly clinical workload for DP enrollees. This file will be uploaded through the TRICARE DP Portal or submitted via SFTP by the 15th of each month (or as posted in the Annual DP Processing Calendar distributed by TMA).

The unique key used to identify each MCD submission is DMIS ID and Unique Patient Reference Number.

1.1.6. MCD Header Record File Specifications

ERROR CODE

1.1.7. MCD Detail Data Record File Specifications

Required field is blank/NULL

Data value not found in DP table

DMIS ID/Patient/Sponsor not found in DP table

008 034

Required field is blank/NULL

Invalid data value

Patient/Sponsor not found in DP Table

Required field is blank/NULL

Field has invalid date format

Required field is blank/NULL

Required field is blank/NULL

Invalid data value

Patient/Sponsor not found in DP Table

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Required field is blank/NULL

Provider not found in DP table

Data value not found in DP table

Required field is blank/NULL

Provider not found in DP table

Must be < $3000 and > -$3000

Required field is blank/NULL

X

X

Required field is blank/NULL

Nbr srvcs doesn’t=nbr srvcs populated

Required field is blank/NULL

Field has invalid date format

Date not>=DOB and Enroll date in DEERS

DOS > 5 years past or 2 years future from submit date

Required field is blank/NULL

Field has invalid date format

Date is outside enrollment dates

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Date not>=DOB and Enroll date in DEERS

DOS > 5 years past or 2 years future from submit date

Required field is blank/NULL

Date is outside enrollment dates

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Date not>=DOB and Enroll date in DEERS

DOS > 5 years past or 2 years future from submit date

Required field is blank/NULL

Date is outside enrollment dates

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Date not>=DOB and Enroll date in DEERS

DOS > 5 years past or 2 years future from submit date

Required field is blank/NULL

Date is outside enrollment dates

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Date not>=DOB and Enroll date in DEERS

DOS > 5 years past or 2 years future from submit date

Required field is blank/NULL

Date is outside enrollment dates

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Date not>=DOB and Enroll date in DEERS

DOS > 5 years past or 2 years future from submit date

Required field is blank/NULL

Date is outside enrollment dates

Required field is blank/NULL

Data value not found in DP table

Required field is blank/NULL

Date not>=DOB and Enroll date in DEERS

Field has invalid date format

Adm dt cannot be >3 yrs from submit per DOS > 5 years past or 2 years future from submit date

Required field is blank/NULL

Required field is blank/NULL

Required field is blank/NULL

30 Still a patient

*For use only on Medicare claims for hospital care

Required field is blank/NULL

Field has invalid date format

Date not>=Adm Date

Required field is blank/NULL

TQMC HT9402-15-R-0005, Section J, Attachment J-15

TQMC HT9402-15-R-0005, Section J, Attachment J-15