Transcript The Clinician’s Guide to Answering the Service

The Clinician’s Guide to
Answering the
Service-Connected
Classification
Question
A condition is only service
connected if it has been rated as
an adjudicated service connected
disability through the Veterans
Benefits Administration (VBA).
OBJECTIVES
This presentation will provide staff with
information that will aid in correctly
designating a visit as service connected
(SC) or non service connected (NSC).
The encounter form or computer
screen will display:
Yes
No
Visit Related To:
Service Connected Condition
Combat Vet (Combat Related)
Agent Orange Exposure
Ionizing Radiation Exposure
Environmental Contaminants
MST
Head and/or Neck Cancer
Is treatment for a service connected condition?
It is the responsibility of the provider to mark the
encounter based on their clinical judgment and eligibility
information as: * service connected or *non service
connected
Why the SC/NSC determination
is so important?
 Monitored by:
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Congress
Office of Management and Budget (OMB)
Top VHA Officials
Third Party Payers
Veterans (patients)
 VHA requires this data for:
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Utilization studies
Research
Budgeting
Business Office operations
BILLING REQUIREMENT
Title 38 legislation requires VHA to
bill for care provided for a condition
that is not service connected or a
special authority.
 Bills are processed for non service
connected care, which includes adjunct
and secondary conditions.
What is a service-connected
condition?
refers to a VBA decision that a
veteran’s illness or injury was incurred in or
aggravated by military service.
 “Service-connected”
 VBA establishes the degree of disability for each service
connected condition.
 A veteran may have more than one adjudicated service
connected condition.
 If the primary rated condition worsens over time,
encourage patient to have VBA complete a
reassessment of rated disabilities.
What does the SC % rating represent?
 The percentage ratings represent as far
as can practically be determined
– The average impairment in earning
capacity resulting from such diseases and
– Injuries and/or their residual conditions
in civil occupations.
Other Encounter Classifications
 If applicable the provider should also
indicate if the encounter is for care due to
(special authorities):
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Agent Orange exposure
Ionizing Radiation exposure
Environmental Contaminants
Military Sexual Trauma
Head and/or Neck Cancer
Combat Service
SHAD (Shipboard Hazard and Defense)
Service-Connected billing
 Treatment provided for service connected conditions or
special authorities is not billable
 Exception
– Workers compensation or tort feasor claims for
injury of service-connected disability (Notify your
facility revenue office when you encounter a patient
with a work related injury/condition.)
Reference: M-1, Part I Chapter 15, section 15.02 b (5). VA can bill:
"Veterans for service-connected disabilities when it is medically
determined that re-injury or aggravation of the service-connected
disability is due to a compensable occupational injury or disease or the
negligence or other legal wrong of a third person.”
IMPORTANT
 “Service connected” does not mean that all
treatment a veteran receives is considered to be
service connected
 The treating clinician is responsible for the
determination based on accurate service
connected information within the patient
record, not just from what the patient states,
for each patient encounter and/or medication
prescription.
Where to find information about
the veteran’s service connection
 Electronic Encounter Form
 Consolidated Health Record
 Computerized Patient Record System
 Patient Interview
 Appointment List
 Patient Inquiry
 Appointment Management
 Rating Decision
 Registration and eligibility staff
VBA Rating Codes for Service
connected Conditions
 Vague Codes
– What Do They Mean??
– Where do I find more information?
 The best source to clarify the patient’s rated
condition is the individual rating decision for
the patient.
– For general information about ratings,
codes, and percentages visit the VBA
website:
http://vbaw.vba.va.gov/bl/21/publicat/regs/P
art4/toc.htm
How to make a SC/NSC determination
 The clinician documents all identified
conditions and treatment given during an
encounter. (These may be different than what
the veteran was scheduled).
 Mark the encounter form with the appropriate
diagnostic and procedure codes. Remember:
the clinical documentation MUST support your
choices.
How to make a SC/NSC determination
 Determine if the condition for which the veteran
is treated is specifically for any service connected
condition(s)
 If it is, mark the encounter as service connected.
 If it is not, mark the encounter as Non service
connected.
Medications
 Medications for conditions adjunct/secondary
(associated with) or aggravated by the service
connected rated conditions are billable.
 This includes drugs that may prevent co-morbid
disease progression and/or treat secondary or adjunct
conditions.
 If the medication is for an adjunct/secondary condition,
mark the prescription as Non service connected.
 If the medication is for an adjudicated service
connected condition or special , mark the prescription
as service connected.
Adjunct Conditions
 Remember
If the treatment provided was for a condition
which you consider to be adjunct/secondary
(associated with) or aggravated by the serviceconnected condition(s), you MUST answer NO
to the service connected classification question!
Frequently Asked Questions
Q. Do veterans receive free care at the VA
Medical Center?
A. Not all veterans.
– Most veterans have a Medication co-pay
– Certain priority patients by law through
income-based determinations (Means Test)
must make co-payments
Frequently Asked Questions
Q. If I don’t mark the encounter as serviceconnected, will the veteran be eligible for
the service?
A. Yes. Public Law 104-262, The Veterans
Health Care Eligibility Reform Act of
1996, created a medical benefits package
which is available to all enrolled veterans.
Frequently Asked Questions
Q. If a patient is 100% service connected for a
specific condition, are all their encounters
service connected?
A. No. The percentage (%) of service connection
pertains only to the rated condition. If the
encounter was for a non service connected
condition, it would not be considered a service
connected encounter.
If a patient is 0% or 100%, they are still rated
for that specific condition.
Frequently Asked Questions
Q. Are encounters marked as AO, EC, MST, CV
etc…(special authorities) billable?
A. No
* If check-out under special authorities, such as
Title 38 USC 1710(e), the encounters do not
trigger 1st party charges nor the Integrated
Billing package.
Frequently Asked Questions
Q. Must the veteran’s private insurance company be
billed for conditions that are adjunct or secondary to the
service-connected condition?
A. Yes. Current interpretation of the law:
– Adjunct condition associated with or aggravating a
disease or condition which is service connected
– Secondary condition has been caused or is the result
of a service connected condition
Adjunct and secondary conditions are not service
connected per interpretation of the law and should be
billed to the insurance carrier
Frequently Asked Questions
 If a veteran is treated for both a service connected and
non service connected condition at the same visit,
should the provider, mark the encounter as serviceconnected?
 A. Yes. If the primary diagnosis is service connected,
the visit is marked service connected. If the primary
diagnosis is not service connected and treatment was
provided for a secondary diagnosis that is service
connected (excluding mention of stable chronic
conditions and routine medication refills), the visit is
marked service connected.
Do You Have Other Questions about
the SC/NSC Determination Process?
Contact your local Revenue Office for
assistance.
The End