Briefing: Preparing for 2010 Cosmetic Surgery Rates & Methodology

1. Briefing: Preparing for 2010 Cosmetic Surgery Rates & Methodology Date: 23 March 2010 Time: 1610–1700

2. Objectives • Background – HA Policy 05-020, June 2005 • Overview of Current Cosmetic Surgery Estimator (CSE) Version 5.0 and Rate Methodology • Overview of 2010 Proposed Changes • New Procedures • Deleted Procedures • Because you asked, and we responded • Estimator, Superbill, User’s Guide updates • Helpdesk correspondence • V6.0 rollout process

3. Background Elective cosmetic surgery is not a TRICARE covered entitlement; it’s a benefit and must be paid for However, Health Affairs Policy 05-020 authorizes elective cosmetic surgery in military treatment facilities (MTFs) to “support graduate medical education, board eligibility and certification, and skill maintenance for certified specialists.” HA Policy 05-020, June 2005 The policy also notes that support of our wartime mission demands specialists skilled in reconstructive surgery; therefore military providers “have a valid need to perform cosmetic surgery cases to maintain their specialty surgical skills.” HA Policy 05-020, June 2005

4. Availability of Elective Cosmetic Procedures • Elective cosmetic surgery MTFs is only provided on a “space available” basis and is limited to: • TRICARE-eligible beneficiaries (including TRICARE for Life) who will not lose eligibility for at least 6 months • Active duty personnel who have written permission from their unit commander • All patients are fully responsible for professional fees, applicable institutional and anesthesia charges, as well as the cost of all implants, cosmetic injectables, and other separately billable items associated with elective cosmetic procedures

5. Acknowledgement of Terms All cosmetic surgery patients must be informed prior to surgery that follow-up, including revision surgery, is not guaranteed in the direct care system and that complications of cosmetic surgery procedures are excluded from coverage under TRICARE. –TRICARE Policy Manual, Chapter 4, Section 1.1 “The patient’s medical record must contain a signed acknowledgement of this disclosure.” – HA Policy 05-020, June 2005

6. Current Rate Methodology Professional Charges* (Surgeon’s Fee) + Facility Fee* (There is no facility fee for procedures performed in a provider’s office) + Anesthesia Fee + Cost of Implants & Pharmaceuticals (e.g., Breast Implants, Chin Implants, Botox®, Restylane®) =TOTAL COST * For bilateral or secondary procedures performed during same surgical encounter, fees are reduced by 50% for additional procedures

7. Professional Fees Rate Methodology • Professional Fees – 2009 • Facility Provider • Non-Facility Provider • Why are there two rates associated with professional fees? • HCPCS/CPT codes mapped to CHAMPUS Maximum Allowable Charge (CMAC) national rate* • Professional Fees – 2010 • No change in methodology planned • Update fees to 2010 CMAC national rate* • *Elective cosmetic surgery rates are global to all MTFs and not based on a facility's geographic location

8. Outpatient Facility Rate Methodology • OP Facility Fees – 2009 • Outpatient (APU setting) • Implemented TRICARE Ambulatory Payment Classification (APC) rates associated with the principal procedure, and 50% of the APC rate for each additional or bilateral procedure • Resulted in higher facility fees in 2009 – but some lower • OP Facility Fees – 2010 • Future revisions under consideration to incorporate input from a wide selection of stakeholders • TMA’s Office of the Chief Medical Officer (OCMO) collaborating with TMA/UBO to better align clinical interests with Business Office requirements

9. Inpatient Facility Rate Methodology • Inpatient Facility Fees – 2009 • DRG driven by mapping CPT codes to ICD-9 procedures • DRG weight multiplied by TRICARE’s Average Adjusted Standardized Amount (ASA)*, rounded to nearest $10 Example: RWP=0.5146 x $4696.60*= $2416.87 $2420.00 • Additional cosmetic procedures performed have a flat rate of $1,000.00 per additional procedure • When combined with medically necessary procedure(s), 50% of DRG is assessed along with 50% of anesthesia cost, and 100% of professional fee • Inpatient Facility Fees – 2010 • No changes planned in methodology-will validate DRG and apply 2010 ASA rate ($4835.85)

10. Anesthesia Rate Methodology • General/MAC Anesthesia Fees – 2009 • Fee is derived using the median TRICARE Physician Conversion Factor multiplied by the sum of the number of base units and the National Average Time Units* and rounded to the nearest $10.00 * The National Average Time Units data is compiled using the CMS 2005 Standard Analytical File for professional containing 77 million procedures on 41 million professional claims • Anesthesia Fees – 2010 • No changes planned other than to validate average time units and update to 2010 TRICARE Physician Conversion Factor • The anesthesia fee applies to the highest value procedure, regardless of the number of procedures performed

11. Implants & Pharmaceuticals • Implant Charges • “Patient[s] must reimburse the MTF for any cosmetic implants.”HA Policy 05-020, June 2005 (Emphasis added) • Implants are local purchases, therefore, cost varies by MTF • Pharmaceuticals (Botox, Dermal Fillers, etc.) • 2010 update to include new dermal products • 2010 Update • No changes in methodology planned

12. Enhancements/Fixes to CSE v6.0 • Adding global-period days to the rate table • Some procedures have a 10- or 90-day global period • This information will allow providers to perform “touch-ups,” etc., without re-charging the patient; but they can’t re-code • Saving CPT Glossary and estimates in .pdf format, if possible • Prevent add-on codes from being priced in Box 1 & 2 • Revise comment box prompts to better explain action needed • Add RVUs to the rate table to assist with pricing highest procedure as primary • Review multiple procedures/quantity/sessions logic ANY MORE SUGGESTIONS?

13. Other 2010 Changes/Updates • Not many code additions or deletions anticipated • Coordination with OCMO planned • Superbill update • Change some descriptions and correct code typos and omissions • Add a symbol to designated add-on codes • What’s with code 15847? A teaching moment... • Alternatives to the Superbill provided by the UBO Program Office are not approved • Use of alternative Superbills increases the risk of incorrect/incomplete pricing

14. Other 2010 Changes/Updates, Cont’d • User’s Guide Update • Add guidance requiring Superbill use as published • Add global days to procedures that have them assigned • Add RVUs to rate table for primary procedure pricing • Except Y-codes which are internal-refer to pricing • Update Sample Letter of Acknowledgement • Clarify the refund policy referenced in paragraph 2, and ensure that the refund policy appears on the back of each Letter of Acknowledgement • Clarify business rule regarding rate increases or refunds occurring after payment but before the date of service

15. Use drop down arrow to select CSE Version 5.0 Main Screen Add-on Cost will be broken out to reflect separate fees Privacy Alert: Save/Remove/Reset an Inquiry Export a Report as a .pdf

16. Can fields for the patient name and/or last four digits of social security number be added to the cost estimate report? No, prohibited by patient privacy provisions Side Note: Cosmetic Surgery Estimate Reports should not be saved to a desktop with either personal health information (PHI) or personally identifiable information (PII) unless appropriate HIPAA precautions are taken Can a date of surgery field be added to the CSE Cost Estimate Report generated for the patient? No, surgery dates are unavailable at the time a cost estimate report is generated. Surgery dates should not be scheduled until the patient has received the cost estimate report and paid for his or her procedure in full. Responding to Input Received

17. Distribution of CSE V6.0 & Materials • CSE Database and all associated materials will be available for download from a secure Altarum SharePoint internet site for access control • Suggest you save older versions of the CSE tool • MTF user names and passwords distributed to your Service Manager who will disseminate information to appropriate staff • Distribution of the Estimator is controlled through site IDs and passwords and any request for the Estimator must be forwarded to the appropriate Service Manager for approval and then to the UBO Helpdesk.  UBO staff are not authorized to distribute the Estimator outside their own offices. 

18. Helpdesk Assistance & Resources • UBO.Helpdesk@altarum.org • Include “Cosmetic Surgery” or “CS” in subject line • Queries that are policy centric (e.g., physician requests, pricing exceptions, medical necessity clarification) will be elevated to the UBO Program Manager and Deputy Program Manager for coordinated response – a ticket will be opened and tracked • You should cc your Service Manager on Helpdesk questions • Technical issues like download issues or program navigation challenges are responded to quickly • Together with the strong MSA staff and leadership across the MHS enterprise, we will continue to “refine and define”

19. Questions Questions or Comments?