Legislative Mandate
Under 10 U.S.C. 1079(h) and 1079(j)(2), TRICARE was mandated to adopt Medicare’s reimbursement rules when practicable. Based on these statutory provisions, TRICARE will adopt Medicare’s prospective payment system for reimbursement of hospital outpatient services.
Present on Admission (POA)
POA Indicators for Inpatient Admissions required on Inpatient Claims for admission dates on or after October 1, 2009
"Present on Admission" is defined as symptoms or conditions present at the time the inpatient order/admission occurs. POA is assigned to the principle diagnosis and/or any subsequent secondary diagnoses, and E-codes reported as an additional diagnoses. Beginning October 1, 2009, all inpatient claims with admission dates on or after October 1, will look for the POA indicator applied. Claims for admission dates on or after October 1, 2009 missing a POA indicator where expected will deny and require a corrected claim to be submitted.
Overview
The TRICARE Outpatient Prospective Payment System goes into effect beginning May 1, 2009. Under the OPPS, hospital outpatient services are paid on a rate-per-service basis that varies according to the Ambulatory Payment Classification (APC) group to which the services are assigned. Group services identified by Health Care Procedure Coding System (HCPCS) codes and descriptors within APC groups are the basis for setting payment rates under the hospital OPPS. To receive TRICARE reimbursement under the OPPS, providers must follow all Medicare specific coding requirements, except in those instances where TMA develops specific APCs for those services that are unique to the TRICARE beneficiary population.
Differences between TRICARE and Medicare OPPS
While the TRICARE OPPS is modeled after the Medicare OPPS, there are some differences in the two systems, such as covered benefits and copayments. The TRICARE Outpatient Code Editor will reflect these differences allowing payment for those services that are covered under TRICARE, but not under Medicare and vice versa. In addition TRICARE will retain its current hospital outpatient deductible, cost sharing/copayment amounts and catastrophic loss protection under its OPPS. Following is a summary of the notable differences between TRICARE and Medicare’s OPPS.
OPPS –Inpatient Only Services for TRICARE
TRICARE has identified specific services designated as “inpatient only”. A number of these procedures/services were at one time processed as outpatient services. With the implementation of OPPS, these inpatient only services will only be covered if delivered in an inpatient setting. A list of
inpatient only procedures are available on TRICARE's web site.
Providers building referrals for these procedures for place of service “outpatient setting” will be contacted to update the referral/auth to place of service “inpatient setting”. Visit TRICARE's web site if you need more information on the
implementation and details of TRICARE OPPS.
