Ambulatory Surgery Billing Requirement Update

As a reminder, all ambulatory surgery services with dates of service May 1, 2009 and after must be submitted on a CMS 1450 UB-04 claim form. TRICARE will no longer accept these services on a CMS 1500 with the SG modifier; and claims submitted on a CMS 1500 after May 1 will be returned.

Ambulatory surgical services claims need to be submitted on a UB-04 per the provisions of the TRICARE Reimbursement Manual. The TRICARE Outpatient Prospective Payment System (OPPS) also requires TriWest to use the CPT/HCPCS code and not the revenue code to determine payment. Please note that the revenue codes should be matched with the procedure code relevant to that cost center; e.g., drug revenue codes should carry drug codes, supply revenue codes should carry supply codes. Surgery codes should be billed only on surgery revenue codes. Claims that use the surgical procedure code on non-surgical revenue codes will be returned to the provider for proper coding.

You can continue to submit your claims electronically via the secure provider portal at www.triwest.com/provider without purchasing any new software. If you are not currently registered, go to the “Register Today” link in the upper left corner of the Provider Connection page to set up an account.

For additional information please refer to TRICARE Reimbursement Manual, Chapter 9, Section 1. The TRICARE manuals can be found at http://manuals.tricare.osd.mil/.

Published Date: 05/20/2009