Tricare Philippines Newsletter
How to File a Claim for the Inpatient
Professional Fee Portion of a Hospitalization Part I
Because of the
complexity involved with preparing the inpatient professional fees we
will break the discussion into two parts. Part I will address none
surgical care while Part II will address surgical care. However claims
involving inpatient surgical procedures will have to apply the
processes discussed here as well.
medical industry uses a system of detailed listings of procedures with
unique codes, known as Current Procedural Terminology (CPT) codes,
which are individually costed for
reimbursement. The system was developed by the American Medical
Association and adopted by Medicare and private insurance as the
standard for filing claims in the U.S. and is complex and
growing more complex each year. Currently there are around 8,800
individual codes, each representing a procedure that is billable; in
some cases the current policy requires that the provider group or what
they call “Bundle” two or more codes together under one code for
billing purposes. By 2014 the number of individual codes and procedures
are expected to dramatically increase with the implementation of CPT-5.
No other country in the world uses this system. A few industrial
nations have adopted similar but less complex, methods for billing of
medical care. However much of the world, and in particular third world
countries, simply provide a bill that indicates “Professional Fees”,
“Professional Services” or something similar.
The TRICARE Management Activity (TMA) requires the claims contractor to
take claims and code the procedures using the CPT coding system while
processing the claim so they can input the procedures into the TMA
database. With the exception of the Philippines
this is not a problem because outside these two countries the claims
contractor is authorized to pay “Billed Charges”. What that means is
whatever amount is included on the bill is paid as long as there is a
legitimate bill and receipt. If the bill reflects Professional Fees and
an amount for inpatient professional fees the claims contractor will
code the entire cost to something like “99232 Subsequent Hospital Care”
and charge the entire fee against that code. If the amount of the
bill is $300 or $4,000 it all is charged against that code and approved
But because TMA decided to implement a Champus
Maximum Allowable Charge (CMAC) table in the Philippines
and use the U.S.
system of detailed procedures and coding, if the claims contractor does
the same thing with a similar bill from the Philippines, most of the
billed amount would be disallowed as over the allowable charge. That’s
because CPT code 99232 carries a CMAC rate of $36.43. So if the billed
amount is $300 or $4,000 they will only allow $36.43 and then pay 75%
of that. This happens because the two systems are not compatible
although TMA continues to believe that all county’s medical industry
practices follow the U.S.
standards of billing.
Below is a quote from a recent response to a congressional inquiry
where we tried to address this very issue. It clearly shows that TMA
expects local providers to learn the complex U.S.
billing system of detailed procedures and to breakout their global fee
across these procedures IAW the CMAC TMA built for the Philippines.
That would mean that local providers would have to be familiar with
close to 9,000 separate and distinct procedures, as defined for the U.S.
only, before they could do this. Since TRICARE beneficiaries represent
only about 0.01% of the local patient population, it is unlikely any
health care providers will feel compelled to do this. For anyone that
has asked a provider to do this, they clearly know it will not happen
and even if they tried to identify procedures they will not understand
the detailed breakout used in the U.S. nor will they have any idea how
to distribute the charge across them.
beneficiaries who submit a claim for reimbursement to the TRICARE
Overseas Claims Processor are required to complete the claim form DD
2642, Patient's Request for Medical Payment, and attach the following
information that is normally provided by the provider on his or her
- Doctor's or provider's
name/address (the one that actually provided the care). If
there is more than one provider on the bill, circle his or her
- Date of each service.
- Place of each service.
- Description of each surgical
or medical service or supply furnished.
- Charge for each service and,
- The diagnosis should be
included on the bill.”
As we get further into what has to be done it will become
clear that what TMA demands is not feasible and clearly shows they have
no understanding of how medical industries in other countries operate.
A review of the 2009 claims data showed that only 6% of the billed
amount, of all beneficiary filed claims for inpatient professional
fees, was approved as within the CMAC which clearly demonstrates their
concept of what is required and who will provide it is flawed.
The Four Step Process to
Itemizing a Non-Surgical Claim for Inpatient Professional Fees
The first step is to determine what U.S. procedures are
included in your typical non-surgical inpatient professional global
fee. You will have at least one provider who is your primary provider
for the episode of care. On rare occasions, where there are multiple
issues that span multiple body systems, you may have two primary
providers. In either case these rules will apply to both.
The primary provider(s) will generally visit you at least once each
day. In some cases they may have a resident that stands in for them but
these visits should be considered the same as visits from the primary
provider since the local medical industry holds your physician
responsible for what they do. The U.S. system dictates three
kinds of visits that are attributed to a primary provider and which are
used to determine how much they are paid for your care. They are
“Initial Hospital Visit”, “Subsequent Hospital Visit” and “Discharge
Visit”. So if you were in the hospital for 5 days you would list them
as shown in the example table below.
You may also have one or more consultants that your
primary physician request evaluate you for a condition that is in their
specialty area. Generally these providers will see you twice, once to
examine you and order any necessary tests and once to relay their
findings to you; if the second visit doesn’t occur don’t list it. The U.S.
dictates two kinds of visits that are attributable to a consultant.
They are “Inpatient Consult, New/Established Patient Visit” and
“Subsequent Hospital Visit”.
TMA requires that the claim also include individual charges for each
procedure. Local providers are not aware that many of the actions they
accomplish are considered separate acts or procedures that have to be
identified in the unique U.S. medical billing system
and most do not see their visits as individual billing acts. Also,
because they bill using the common global billing method, they are
unable to provide any reasonable breakout of their global bill across
the individual procedures because that is never done in the Philippines.
In addition, since TMA uses a CMAC that mirrors varying percentages of
the U.S. CMAC, any breakout they might provide is unlikely to reflect U.S.
billings at the individual procedure level. The end result would be
that some of the individual procedures may be priced at well below the
CMAC rates while others maybe well over which would inappropriately
result in underpayment of the total claim.
So to properly determine how the global bill should be distributed
across the individual procedures the CPT code for each procedure must
be determined so the appropriate CMAC rates can be determined. The
issue for the average beneficiary is that the medical coding process is
very complex and requires extensive training to be able to code
for basic non-surgical inpatient professional claims only a group of
codes known as Evaluation and Management (E&M) codes are required
more than 90% of the time.[ii]
Based on our experience Wisconsin Physician Services
almost always pays these at an intermediate level. So the table below
reflects the CPT codes the average beneficiary can use to assign to the
Once you have determined the appropriate CPT code to assign to each
procedure you then need to determine the CMAC rates that apply to the
codes listed for your claim. To do this one has to access the TMA web
page that provides these rates.[iii] Once
you access the appropriate web page there are multiple steps you have
to take before you can start the process. See
to Access the Philippine CMAC.
Go to Philippine
CMAC to start accessing the Philippine CMAC.
This is the results of a search for the four CPT codes above.
Once you determine the actual CMAC rates you can then determine how
much of the global bill can be allocated to each procedure. The good
news is that currently these rates are adequate to cover the normal
amount of the global bills for non-surgical admissions. That may change
in the future since TMA does not make adjustments for Philippine
inflation or decreases in exchange rates which have reduced the value
of the CMAC rates by close to 30% to date.
Determine the exchange rate on the day of discharge from the hospital.
Go to Historical
Rate Tables and follow the instructions on the web
page. Once you follow the instructions look down the resultant web page
and select the Philippine peso rate under the “Units per USD” column.
In our example above it is PHP 44.1499999744. For our purposes we want
to round it off to two decimal places, or PHP 44.15. Because the rate
WPS uses, based on their contract with TMA, comes from CITI Bank you
will have to reduce the rate by 2% which approximates their profit for
making the exchange. The easiest way to do this is to multiply the
rounded rate by 0.98.
For our example from above we will assume a global fee of
PHP 8,000 for the primary physician and PHP 2,500 for the consultant.
Use these to calculate the dollar equivalent so you can decide how to
split the global fee across the procedures, then round them off. In
this example they would be rounded to $185 and $58.
Once you have the dollar equivalent of the actual peso
charges use the CMAC rates you previously looked up to determine how to
distribute the global charge against each of the procedures. Then
reverse the process and convert the individual procedure dollar charges
back to pesos using the previously obtained exchange rate. In most
cases the total pesos will not exactly match the original global bill
amount due to rounding. So create an additional column and make minor
adjustments to these calculated peso amounts so the total matches the
actual global amount. If a procedure is listed more than once insure
the amount allocated to the procedure is the same for each instance for
the same provider. It may be different from one provider to another
however. Repeat the process for each provider. The tables below show
the outcome of each of these steps.
Now use the final individual peso charges to create
tables/lists as shown below. Place them in your narrative and be sure
to include the provider’s full name and address above each table/list.
See our Newsletter, Basic
Claim Filing Rules for the Philippines,
for basic guidance on how to prepare a narrative.
Narrative, for an example of how the itemized
lists are incorporated.
For those interested, we prepared an Excel spreadsheet,
with the formulas imbedded that can be used to do these calculations.
It can be opened and then saved on your computer by clicking on
to Professional Fees Claim Worksheet.
Learn More about CPT Codes
For those that wish to become more familiar with U.S.
medical coding, the following links are provided.
of CPT codes
University Offers a free basic Evaluation and
Management codes (E/M) coding course.
of Contents for E/M Tutorial Area of interest for
inpatient professional fees is items 15, 16 and 17.
Coding Online Offers the ability to look up CPT
codes for free by entering a key word or phrase.
The next newsletter will address the specific issues involved with
preparing a claim for a hospitalization where the professional fees
include surgical procedures and an anesthesiologist. This will be
followed by a newsletter that addresses the issues involved in
preparing a claim for a group of laboratory tests that are billed under
a global bill with a description of “Executive Panel B” or something
Previous Newsletters can be accessed by going to
Military Retirees of the Philippines Group TRICARE Newsletter Archive.
Share this newsletter with other
Forward this newsletter to others you feel might benefit
from them so they can sign up as well. If you represent an RAO or
service organization let your members know so they can sign up. Sign
If you are on Facebook share this newsletter with your
The CMAC lookup process, which TMA provides on their web
page, requires the individual enter the appropriate CPT code. Coders
that perform this for physicians and hospitals in the U.S.
have a 2 or 4 year degree in medical coding.
codes are groups of codes that describe various levels of Initial
Hospital Visits, Subsequent Hospital Visits, Discharge Visits,
Inpatient Consult, New/Established Patient
Visits. Each level carries the same description but the CPT code
reflects increasing complexity and time involved in the visit. Initial Hospital Visits and Subsequent
Hospital Visits each have three levels. Discharge Visits have two while
Inpatient Consult, New/Established Patient Visits have five.
time to time, when Medicare updates their fee schedule, TMA makes
adjustments to the Philippine CMAC. It is best to look up the rates as
soon as possible after treatment. If the care was provided some time in
the past the current rates may not reflect the rates at the time of
care. The older rates are available from the TMA website for download
and can be used in these cases.