Ken FanDubai Health Insurance Corporation, DHA

Disclaimer

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This document has been created by or on behalf of the Dubai Health Authority (DHA). It may only be accessed, downloaded and used by Providers and Payers within the Insurance System for Advancing Healthcare in Dubai (ISAHD) network or those intending to enroll in the ISAHD network, and subcontractors of the DHA (each an Authorized User) as part of the ISAHD’s work in the Emirate of Dubai. No other individual or organization may access, download or use it without prior consent from the DHA.

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The DHA makes no representations, warranties or guarantees of any kind whether express or implied that the content of this document is accurate, complete or up-to-date. To the extent permitted by law, we exclude all conditions, warranties, representations or other terms which may apply to this document, whether express or implied.

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Agenda

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• DHI Price Regulation Task Force• New DRG Adjudication Rules• New Coding Updates• DRG Outlier Calculator Revisions • Finalizing DRG Negotiation Factors• 3M CodeFinder and Grouper Software• Q&A

DHI Price Regulation Task Force

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Hospitals Insurers

Terms of Reference

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• Develop health insurance adjudication standards and manuals

• Discuss operational health insurance adjudication queries

• Advise on market perspectives in the development of health insurance payment models for:

o Inpatient services

o Long term care

o Day care

o Outpatient services

• Advise on market perspectives in the development of paying for performance program,

including performance measurements and reward mechanism

• Advise on market perspectives in the development of costing standards for health insurance

price regulation

Dubai Health Insurance Adjudication Manual v1.0

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• 11 Adjudication Rules

• Effective as of 1 September 2020

• Updated regularly

Pre-Authorization and Final Submission of DRG Code

• Providers are to submit an initial DRG code Insurers for pre-approval.

• Providers are to update the pre-authorization DRG code within 48 hours of patient discharge

before submitting the claim to the payer.

• Payers are to respond back within 48 hours post receipt of the revised DRG code.

• Payers are not to reject any justifiable revision of DRG code at time of claim submission.

Note:

Discharge date/time is a mandated field with effect from 1 September 2020. It is part of the claim

submission schema indicated as “EncounterEnd”. Please refer to the following link for details:

https://www.eclaimlink.ae/dhd/encounterend.html

Splitting of DRG Payments Between Two Payers Due to Change of Insurer During a Patient Episode

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The following formulas applies:

• Total DRG Payment = Base Rate x Relative Weight (including Outlier and Add-On Payments)

• Total DRG Payment Per Day = Total DRG Payment / Total LOS (exclude NF)

• Insurer A Payment = Total DRG Payment Per Day x LOS (Insurer A) x Negotiation Factor (Insurer A)

• Insurer B Payment = Total DRG Payment Per Day x LOS (Insurer B) x Negotiation Factor (Insurer B)

Billing DRGs for Transfer Cases (Not Within the Same Hospital Group)

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• When a patient is transferred from hospitalA to hospital B, Hospital A submits a DRGclaim that is paid per diem where the firsthospital day is paid at 100% and subsequentdays paid at 50% capped at the DRG inlierpayment. Hospital B submits a full DRGclaim for the episode in Hospital B.

Discharge Medication in DRG Payments

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• DRG payments includes dischargemedication of up to 7 days maximumcalculated from the date of discharge.

Applying Mark-up on Price of Consumables and Drugs for High Cost Add-on Payments

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• Hospital mark ups are not permitted whensubmitting claims with add-on payments.Hospitals are requested to submit the invoicedirectly from the supplier.

Surgical Kits in High Cost Add-on Payments

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• Individual items in surgical kits will need to beseparated and each individual item will need tomeet the add-on payment criterion in order tobe eligible for additional payments.

Insurance Policy Excluded Services and DRG Billing

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• Hospital services that were provided but arenot covered in the insurance policy should notbe reported as part of the DRG submission.Services not covered in the insurance policyshould be settled between patient and hospital.

Royal Suites and VIP Room Charges

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• DRGs provides a standardized payment for theservices provided. Room charges are alreadyincurred in the base rate calculations. Anyadditional room charges will be settledbetween the patient and the hospital. Hospitals,at their discretion, may offer a better roomswithout charging the patient.

Patient Hoteling

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• Patient should be clinically and administrativelydischarged upon the completion of patient care.If the patient decides to continue to stay in thehospital, the patient should be billed separatelyfrom the DRG payments.

Billing Methodology for Paying Community-Based and Visiting Surgeons

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• Clinicians’ bills should be reported as part ofthe DRG claim submission by the hospital.Clinicians will not be billed separately from theDRG claim submission.

Billing Methodology for “Send Out” Services

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• Send out services are those cases where thepatient is accompanied by the hospital toanother facility to receive service. Payments forsend out services should be arranged internallybetween hospital and the facility. The send outservice will not be part of the DRG claim fromthe hospital.

Lesley LauDubai Health Insurance Corporation, DHA

Medical Coding for COVID-19

Code Description

U07.1 COVID-19

Code Description

86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative,single step method (eg, reagent strip); severe acute respiratory syndromecoronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)(Coronavirus disease [COVID-19])

87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratorysyndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplifiedprobe technique

CPT

ICD-10-CM

New Codes:

Medical Coding for COVID-19

HCPCS

New Codes:

Code Description

86318 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative,single step method (eg, reagent strip);

Code Description

U0001 CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel

U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multipletypes or subtypes (includes all targets)

CPT

Updated Code:

Medical Coding for COVID-19ICD-10-CM Reporting Guidelines:

To report confirmed cases, assign code U07.1 “COVID-19” then followed by the specific respiratory

condition (e.g. pneumonia, acute bronchitis or unspecified acute lower respiratory infection etc.).

Only assign signs and symptoms codes where a definitive diagnosis has not be established.

To report suspected cases, assign Z20.828 “Contact with and exposure to other viral communicable

diseases”.

To report negative cases, assign Z03.818 “Encounter for observation for suspected exposure to other

biological agents ruled out”.

To report screening for asymptomatic cases, assign Z11.59 “Encounter for screening for other viral

diseases”.

To report asymptomatic cases with positive test result, assign U07.1 “COVID-19”.

To report infection during pregnancy, childbirth or the puerperium, assign O98.5x, Other viral diseases

complicating pregnancy, childbirth and the puerperium then followed by U07.1 “COVID-19”.

Medical Coding for COVID-19

CPT and HCPCS Reporting Guidelines:

For infectious agent detection by nucleic, assign 87635 “Infectious agent detection by nucleic acid

(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease

[COVID-19]), amplified probe technique”

For antibody detection, assign 86328 “Immunoassay for infectious agent antibody(ies), qualitative or

semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])” or 86769 “Antibody; severe acute

respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])” for multiple

steps.

For other specified methods, assign U0002 “2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-

19), any technique, multiple types or subtypes (includes all targets)”.

New Covid-19 DSL Codes

DSL CodeProcedureCPT Code

Description

90.13 93000 ECG 12 LEADS equivalent to CPT 93000

90.14 71010 XRAY CHEST PA equivalent to CPT 71010

90.15 86140 C-REACTIVE PROTEIN(CRP) equivalent to CPT 86140

90.16 82728 FERRITIN equivalent to CPT 82728

90.17 83615 LDH equivalent to CPT 83615

90.18 80076 LIVER PANEL equivalent to CPT 80076

90.19 80069 RENAL PANEL equivalent to CPT 80069

90.20 84145 PROCALCITONIN equivalent to CPT 84145

90.21 85025 CBC equivalent to CPT 85025

90.22 85730 PTT equivalent to CPT 85730

90.23 99000 COVID-19 PROCESSING /COLL equivalent to CPT 99000

63.06 Dr. Rounding Fees for Covid-19

New Teleconsultation DSL Codes

DSL Code Description

41 Teleconsultation – GP

42 Teleconsultation – Specialist

43 Teleconsultation – Consultant

44 Teleconsultation – Allied Health

45 Teleconsultation – Psychotherapy (Psychologist)

46 Teleconsultation – Psychiatry (Adult)

47 Teleconsultation – Psychiatry (Child)

DRG Outlier Calculator Revisions

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Version 2.2 Includes:

• 2018 CPT codes

• 2018 HCPCS

• DDC list as of 6 July 2020

• New cost updates

Budget Neutral DRG Negotiation Factor

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Paid Amounts

Patient Share

InlierPayment

Outlier Payment+ Add-On

Payment

If Applicable

=

Fee For Service DRGs

• If this is not the case the negotiation factor needs to be adjusted to ensure this equation is achieved.• Patient share refers to the patient policy limit, not out-of-pocket amounts

Note