1 TMA UBO CY 2007 OIB Rate Package Release Presented by UBO Project Support Team June 19 th : 0800, 1400 & 2100 EDT June 21 st : 0800 & 1400 EDT Dial in: (866) Participant code:

2 Agenda CMAC CMAC Component Rates Associated Rate Tables (MEPRS Based Rates) Mapping Table Updates Pharmacy Rates Questions

3 CMAC Rates - Overview CMAC 391 locality is new – for OCONUS Added rate for CPT code “ 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 ” )

4 CMAC Emergency Dept (ED) rates 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

5 CMAC ED Rates Compare CPT Code ’ 06 rate ’ 07 rate% change 99281$ 89.25$ (44)% 99282$ 99.77$ (17)% 99283$ $ (31)% 99284$ $ (34)% 99285$ $ (12)%

6 CMAC Component Rate File Added PET Scan for professional, technical and global rates CPT codeProfessionalTechnicalGlobal 78608$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 85.54$ $ $ 85.54$ $ $ 85.54$ $ $ 95.00$ $ $ 95.00$ $ $ 95.00$ $

7 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

8 Ambulance Rate – Price Compare CPT code ’ 06 rate ’ 07 rate% change A0999 FOR:$ $ % IOR:$ $ % IMET:$ 87.00$ %

9 Anesthesia Rate – Price Compare ’ 06 rate ’ 07 rate% change FOR:$ $ % IOR:$ $ % IMET:$ $ %

10 APV Rate – Price Compare CPT code ’ 06 rate ’ 07 rate% change FOR:$ 1,299.00$ 1, % IOR:$ 1,231.00$ 1, % IMET:$ $ %

11 Dental Rate – Price Compare CDT codes ’ 06 rate ’ 07 rate% change FOR:$ $ (4)% IOR:$ 95.00$ (4)% IMET:$ 40.00$ %

12 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

13 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)

14 Immunization Rate – Price Compare ’ 06 rate ’ 07 rate% change FOR:$ 47.00$ % IOR:$ 44.00$ % IMET:$ 26.00$ %

15 Observation Rate – Price Compare CPT code ’ 06 rate ’ 07 rate% change 99218:$ $ * 33% 99219:$ $ * 28% 99220:$ $ * 17% * Institutional component only

16 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

17 Mapping Table Updates TPOCS Mapping Table CPT Revenue Mapping Table Modifier Mapping Table DMIS ID Mapping Table

18 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, & 99373

19 CPT Revenue Mapping Table Added 280 new CPT codes Deleted 112 CPT codes Added 387 new HCPCS codes Deleted 124 HCPCS codes

20 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)

21 DMIS ID Mapping Table Mapped all OCONUS sites to “ 391 ” Mapped all 5400 sites to locality “ 000 ”

22 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???

23 TMA UBO Pharmacy Rates Update Presented by the UBO Support Team June 2007

24 Pharmacy Rates Update Pharmacy rate file submitted to CITPO and RITPO (66,654 drugs) Effective June 30, 2007

25 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

26 Unit Measure Price Comparison Rate FileSimple 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) $ % Unit Measure Price Comparison- Existing Rate to Updated Rate (Top 100 GSNs) 10.01%

27 Unit Measure Price: Market Comparison Rate FileSimple 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

28 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

29 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

30 Questions Questions?