TRICARE CHAMPUS Maximum Allowable Charge (CMAC) changes for 2005 are effective for services rendered on or after April 1, 2005. The most significant changes to the CMAC include payments based on “site of service” as TRICARE will now implement this payment methodology in place for Medicare.
Although a new concept to TRICARE, payment based on site of service is a concept used by Medicare to distinguish between services rendered in a facility setting as opposed to a non-facility setting.
Prior to April 1, 2005, the CHAMPUS Maximum Allowable Charge (CMAC) was established at a rate dependent only on the category of the provider (MD and other specialties, and non-MD providers). Even in site of service pricing, for some services such as radiology and laboratory tests, the facility and nonfacility payment levels are the same.
In addition, prior to April 1, 2005, CMAC pricing was established by class of provider (1, 2, 3, and 4). These four classes of providers will be superseded by four categories.
Category 1: Services of MDs, DOs, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, and audiologists provided in a facility. These include hospitals (both inpatient and outpatient where the hospital is generating a revenue bill; i.e., revenue code 510), residential treatment centers, ambulances, hospices, military treatment facilities, psychiatric facilities, community mental health centers, skilled nursing facilities and ambulatory surgical centers.
Category 2: Services of MDs, DOs, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, and audiologists provided in a non-facility. These include provider offices, home settings, and all other non-facility settings.
Category 3: Services of all other providers not found in Category 1, provided in a facility. These include hospitals (both inpatient and outpatient where the hospital is generating a revenue bill; i.e., revenue code 510), residential treatment centers, ambulances, hospices, military treatment facilities, psychiatric facilities, community mental health centers, skilled nursing facilities and ambulatory surgical centers.
Category 4: Services, of all other providers not found in Category 2, provided in a non-facility. These include provider offices, home settings and all other non-facility settings.
Linking the Site of Service with the Payment Category
TriWest Healthcare Alliance is responsible for linking the site of service with the proper payment category. The rates of payment are found on the CMAC files that are supplied to TriWest by the TRICARE Management Activity (TMA).
Payment of Facility Charges When the 510 and 760 Series Revenue Codes are Billed
Effective for dates of service on or after April 1, 2005, payment of 51x and 76x series revenue codes shall begin. Payment will be based on contractual terms for network providers or as billed. Facilities that bill with Revenue Code 51x series will now receive reimbursement. Professional providers who provide services in a hospital setting may experience a decrease in reimbursement levels.
Revenue Code 51x
For dates of service prior to April 1, 2005, TriWest considers the TRICARE allowable charge reimbursement for covered medical services to include overhead and administrative costs. Therefore, revenue code series 51x is not reimbursed separately. Charges submitted with revenue code series 51x are rebundled and denied with the explanation, “Reimbursement for this service was considered to be paid as part of the professional services. No additional reimbursement will be made. This charge may not be billed to the TRICARE beneficiary.”
Facilities billing with revenue code series 51x will be reimbursed for dates of service on or after April 1, 2005. Adjustments for claims with dates of service prior to April 1, 2005 will not be considered.
Revenue Code 76x
Effective April 1, providers may indicate revenue code 76x for the actual use of a treatment room in which a specific procedure has been performed or a treatment rendered. Revenue code 76x may be appropriate for charges for minor procedures and in the following instances:
- An outpatient surgery procedure code (10040-69990)
- Interventional radiology services related to imaging, supervision, interpretation, and the related injection or introduction procedure
- Debridement (11040-11044) performed in an outpatient hospital department
Revenue code 76x should not be used when the claim is submitted with a type of bill 83x and ASC procedure codes. ASC facility services are reimbursed under the ASC revenue code reimbursement.
Services and Procedure Codes Not Affected by Site of Service
Anesthesia services, laboratory services, component pricing services such as radiology and “J” codes are some of the more common services and codes that will not be affected by site of service.
CMAC History Files
TriWest will retain and maintain previous years’ CMAC files for historical purposes. Claims for dates of service previous to April 1, 2005 will be reimbursed based on the CMACs in effect on the date of service.
Place of Service Codes
Professional providers may experience a decrease in reimbursement levels when billing with Place of Service Codes 21, 22 or 23. There will be no change in professional reimbursement if Place of Services Codes are not 21, 22 or 23.
These changes apply to all applicable providers (network and non-network). For network providers, it is not be necessary to amend the current TRICARE agreement because these changes are mandated by TMA.
The new CMAC rates based on site of service will soon be available on the TMA web site.
Posted 03/15/2005