97-27629. Cost of Hospital and Medical Care Treatment Furnished by the United States; Certain Rates Regarding Recovery From Tortiously Liable Third Persons  

  • [Federal Register Volume 62, Number 201 (Friday, October 17, 1997)]
    [Notices]
    [Pages 54131-54138]
    From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
    [FR Doc No: 97-27629]
    
    
    =======================================================================
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    OFFICE OF MANAGEMENT AND BUDGET
    
    
    Cost of Hospital and Medical Care Treatment Furnished by the 
    United States; Certain Rates Regarding Recovery From Tortiously Liable 
    Third Persons
    
        By virtue of the authority vested in the President by section 2(a) 
    of Pub. L. 87-693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to the 
    Director of the Office of Management and Budget by Executive Order No. 
    11541 of July 1, 1970 (35 FR 10737), the three sets of rates outlined 
    below are hereby established. These rates are for use in connection 
    with the recovery, from tortiously liable third persons, of the cost of 
    hospital and medical care and treatment furnished by the United States 
    (Part 43, Chapter I, Title 28, Code of Federal Regulations) through 
    three separate Federal agencies. The rates have been established in 
    accordance with the requirements of OMB Circular A-25, requiring 
    reimbursement of the full cost of all services provided. The rates are 
    established as follows:
    
    1. Department of Defense
    
        The Fiscal Year 1998 (FY98) Department of Defense (DoD) 
    reimbursement rates for inpatient, outpatient, and other services are 
    provided in accordance with Section 1095 of title 10, United States 
    Code. Due to size, the sections containing the Drug Reimbursement Rates 
    (Section III.D) and the rates for Ancillary Services Requested by 
    Outside Providers (Section III.E) are not included in this package. The 
    Office of the Assistant Secretary of Defense (Health Affairs) will 
    provide these rates upon request. The medical and dental service rates 
    in this package (including the rates for ancillary services, 
    prescription drugs or other procedures requested by outside providers) 
    are effective October 1, 1997.
    
    2. Health and Human Services
    
        The sum of obligations for each cost center providing medical 
    service is broken down into amounts attributable to inpatient care on 
    the basis of the proportion of staff devoted to each cost center. Total 
    inpatient costs and outpatient costs thus determined are
    
    [[Page 54132]]
    
    divided by the relevant workload statistic (inpatient day, outpatient 
    visit) to produce the inpatient and outpatient rates. In calculation of 
    the rates, the Department's unfunded retirement liability cost and 
    capital and equipment depreciation cost were incorporated to conform to 
    requirements set forth in OMB Circular A-25. In addition, each cost 
    center's obligations include costs for certain other accounts, such as 
    Medicare and Medicaid collections and Contract Health funds used to 
    support direct program operation. Certain cost centers that primarily 
    support workload outside of the directly operated hospitals or clinics 
    (public health nursing, public health nutrition, health education) were 
    excluded this year as not being a part of the traditional cost of 
    hospital operations and not contributing directly to the inpatient and 
    outpatient visit workload. Overall, these rates reflect a more accurate 
    indication of the cost of care in HHS facilities.
        In addition, separate rates per inpatient day and outpatient visit 
    were computed for Alaska and the rest of the United States. This gives 
    proper weight to the higher cost of operating medical facilities in 
    Alaska.
    
    3. Department of Veterans Affairs
    
        Actual direct and indirect costs are compiled by type of care for 
    the previous year, and facility overhead costs are added. Adjustments 
    are made using the budgeted percentage changes for the current year and 
    the budget year to compute the base rate for the budget year. The 
    budget year base rate is then adjusted by estimated costs for 
    depreciation of buildings and equipment, central office overhead, 
    Government employee retirement benefits, and return on fixed assets 
    (interest on capital for land, buildings, and equipment (net book 
    value)), to compute the budget year tortiously liable reimbursement 
    rates. Also shown for the tortiously liable inpatient per diem rates 
    are breakdowns into three cost components: Physician; Ancillary; and 
    Nursing, Room, and Board. As with the total per diem rates, these 
    breakdowns are calculated from actual data by type of care.
        The interagency rates shown are to be used when VA medical care or 
    service is furnished to a beneficiary of another Federal agency, and 
    that care or service is not covered by an applicable local sharing 
    agreement. Government employee retirement benefits and return on fixed 
    assets are not included in the interagency rates, but in all other 
    respects the interagency rates are the same as the tortiously liable 
    rates.
        Inpatient charges will be at the per diem rates shown for the type 
    of bed section or discrete treatment unit providing the care. 
    Prescription Filled charge in lieu of the Outpatient Visit rate will be 
    charged when the patient receives no service other than the Pharmacy 
    outpatient service. This charge applies whether the patient receives 
    the prescription in person or by mail.
        When medical care or service is obtained at the expense of the 
    Department of Veterans Affairs from a non-VA source, the charge for 
    such care or service will be the actual amount paid by the VA for that 
    care or service.
    
    1. Department of Defense
    
        For the Department of Defense, effective October 1, 1997 and 
    thereafter:
    
    Inpatient, Outpatient and Other Rates and Charges
    
    I. Inpatient Rates 1 2
    
    ----------------------------------------------------------------------------------------------------------------
                                                                       International    Interagency                 
                                                                         Military        and other                  
                            Per inpatient day                           Education &   Federal agency   Other (Full/ 
                                                                         Training        sponsored     Third party) 
                                                                          (IMET)         patients                   
    ----------------------------------------------------------------------------------------------------------------
    A. Burn Center..................................................       $2,618.00       $4,754.00       $5,079.00
    B. Surgical Care Services (Cosmetic Surgery)....................          955.00        1,733.00         1852.00
    C. All Other Inpatient Services (Based on Diagnosis Related                                                     
     Groups (DRG) \3\)                                                                                              
    ----------------------------------------------------------------------------------------------------------------
    
    1. FY98 Direct Care Inpatient Reimbursement Rates
    
    ----------------------------------------------------------------------------------------------------------------
                                                                                           Other        (Full/Third 
                        Adjusted standard amount                           IMET         interagency       party)    
    ----------------------------------------------------------------------------------------------------------------
    Large Urban.....................................................       $2,199.00       $4,131.00       $4,372.00
    Other Urban/Rural...............................................        2,194.00        4,215.00        4,499.00
    Overseas........................................................        2,450.00        5,614.00        5,960.00
    ----------------------------------------------------------------------------------------------------------------
    
    2. Overview
        The FY98 inpatient rates are based on the cost per DRG, which is 
    the inpatient full reimbursement rate per hospital discharge weighted 
    to reflect the intensity of the principal diagnosis, secondary 
    diagnoses, procedures, patient age, etc. involved. The average cost per 
    Relative Weighted Product (RWP) for large urban, other urban/rural, and 
    overseas facilities will be published annually as an inpatient adjusted 
    standardized amount (ASA) (see paragraph I.C.1., above). The ASA will 
    be applied to the RWP for each inpatient case, determined from the DRG 
    weights, outlier thresholds, and payment rules published annually for 
    hospital reimbursement rates under the Civilian Health and Medical 
    Program of the Uniformed Services (CHAMPUS) pursuant to 32 CFR 
    199.14(a)(1), including adjustments for length of stay (LOS) outliers. 
    The published ASAs will be adjusted for area wage differences and 
    indirect medical education (IME) for the discharging hospital. An 
    example of how to apply DoD costs to a DRG standardized weight to 
    arrive at DoD costs is contained in paragraph I.C.3., below.
    3. Example of Adjusted Standardized Amounts for Inpatient Stays
        Figure 1 shows examples for a nonteaching hospital in a Large Urban 
    Area.
    
    [[Page 54133]]
    
        a. The cost to be recovered is DoD's cost for medical services 
    provided in the nonteaching hospital located in a large urban area. 
    Billings will be at the third party rate.
        b. DRG 020: Nervous System Infection Except Viral Meningitis. The 
    RWP for an inlier case is the CHAMPUS weight of 2.9769. (DRG statistics 
    shown are from FY 1996).
        c. The DoD adjusted standardized amount to be charged is $4,372 
    (i.e., the third party rate as shown in the table).
        d. DoD cost to be recovered at a nonteaching hospital with area 
    wage index of 1.0 is the RWP factor (2.9769) in 3.b., above, multiplied 
    by the amount ($4,372) in 3.c., above.
        e. Cost to be recovered is $13,015.
    
                                         Figure 1.--Third Party Billing Examples                                    
    ----------------------------------------------------------------------------------------------------------------
                                                               Arithmetic     Geometric    Short stay     Long stay 
         DRG No.           DRG description       DRG weight     mean LOS      mean LOS      threshold     threshold 
    ----------------------------------------------------------------------------------------------------------------
    020..............  Nervous System                2.9769          11.2           7.8             1            30 
                        Infection Except Viral                                                                      
                        Meningitis.                                                                                 
    ----------------------------------------------------------------------------------------------------------------
    
    
    ----------------------------------------------------------------------------------------------------------------
                                                                Area wage        IME                                
                 Hospital                     Location         rate index    adjustment     Group ASA    Applied ASA
    ----------------------------------------------------------------------------------------------------------------
    Nonteaching Hospital..............  Large Urban.........          1.0           1.0     $4,372.00     $4,372.00 
    ----------------------------------------------------------------------------------------------------------------
    
    
    ----------------------------------------------------------------------------------------------------------------
                                                                      Relative weighted product              TPC    
          Patient            Length of stay      Days above  -------------------------------------------------------
                                                  threshold     Inlier *     Outlier **       Total      Amount *** 
    ----------------------------------------------------------------------------------------------------------------
    #1.................  7 days...............            0        2.9769        0.0000        2.9769       $13,015 
    #2.................  21 days..............            0        2.9769        0.0000        2.9769        13,015 
    #3.................  35 days..............            5        2.9769        0.6297        3.6066       15,768  
    ----------------------------------------------------------------------------------------------------------------
    *DRG Weight                                                                                                     
    **Outlier calculation = 33 percent of per diem weight' number of outlier days = .33 (DRG Weight/Geometric Mean  
      LOS)' (Patient LOS--Long Stay Threshold)                                                                      
    =.33 (2.9769/7.8) ' (35-30)                                                                                     
    =.33 (.38165)' 5 (take out to five decimal places)                                                              
    =.12594' 5 (take out to five decimal places)                                                                    
    =.6297 (take out to four decimal places)                                                                        
    *** Applied ASA' Total RWP                                                                                      
    
    II. Outpatient Rates 1 2 Per Visit
    
    ----------------------------------------------------------------------------------------------------------------
                                                                       International    Interagency                 
                                                                         Military        and other                  
            MEPRS Code \4\                  Clinical service            Education &   Federal agency   Other  (Full/
                                                                         Training        sponsored     Third party) 
                                                                          (IMET)         patients                   
    ----------------------------------------------------------------------------------------------------------------
                                                     A. Medical Care                                                
    ----------------------------------------------------------------------------------------------------------------
    BAA...........................  Internal Medicine...............         $105.00         $195.00         $208.00
    BAB...........................  Allergy.........................           39.00           73.00           78.00
    BAC...........................  Cardiology......................           81.00          150.00          160.00
    BAE...........................  Diabetic........................           44.00           82.00           87.00
    BAF...........................  Endocrinology (Metabolism)......           85.00          158.00          168.00
    BAG...........................  Gastroenterology................          110.00          203.00          216.00
    BAH...........................  Hematology......................          145.00          269.00          287.00
    BAI...........................  Hypertension....................           81.00          149.00          159.00
    BAJ...........................  Nephrology......................          171.00          317.00          338.00
    BAK...........................  Neurology.......................          109.00          202.00          215.00
    BAL...........................  Outpatient Nutrition............           34.00           63.00           67.00
    BAM...........................  Oncology........................          114.00          211.00          225.00
    BAN...........................  Pulmonary Disease...............          141.00          260.00          278.00
    BAO...........................  Rheumatology....................           84.00          156.00          166.00
    BAP...........................  Dermatology.....................           63.00          117.00          124.00
    BAQ...........................  Infectious Disease..............          141.00          260.00          278.00
    BAR...........................  Physical Medicine...............           78.00          145.00          155.00
    BAS...........................  Radiation Therapy...............           72.00          132.00          141.00
    BAZ...........................  Medical Care Not Elsewhere                 84.00          156.00          166.00
                                     Classified (NEC).                                                              
    ----------------------------------------------------------------------------------------------------------------
                                                    B. Surgical Care                                                
    ----------------------------------------------------------------------------------------------------------------
    BBA...........................  General Surgery.................          119.00          220.00          235.00
    BBB...........................  Cardiovascular and Thoracic               110.00          203.00          216.00
                                     Surgery.                                                                       
    BBC...........................  Neurosurgery....................          137.00          253.00          270.00
    BBD...........................  Ophthalmology...................           84.00          155.00          166.00
    BBE...........................  Organ Transplant................          191.00          353.00          376.00
    BBF...........................  Otolaryngology..................           88.00          162.00          173.00
    BBG...........................  Plastic Surgery.................          100.00          184.00          196.00
    BBH...........................  Proctology......................           67.00          124.00          132.00
    
    [[Page 54134]]
    
                                                                                                                    
    BBI...........................  Urology.........................          101.00          187.00          199.00
    BBJ...........................  Pediatric Surgery...............           89.00          164.00          175.00
    BBZ...........................  Surgical Care NEC...............           65.00          120.00          127.00
    ----------------------------------------------------------------------------------------------------------------
                                     C. Obstetrical and Gynecological (OB-GYN) Care                                 
    ----------------------------------------------------------------------------------------------------------------
    BCA...........................  Family Planning.................           45.00           83.00           89.00
    BCB...........................  Gynecology......................           74.00          136.00          146.00
    BCC...........................  Obstetrics......................           68.00          126.00          135.00
    BCZ...........................  OB-GYN Care NEC.................          112.00          207.00         221.00D
    ----------------------------------------------------------------------------------------------------------------
                                                    D. Pediatric Care                                               
    ----------------------------------------------------------------------------------------------------------------
    BDA...........................  Pediatric.......................           54.00          100.00          106.00
    BDB...........................  Adolescent......................           55.00          101.00          108.00
    BDC...........................  Well Baby.......................           36.00           66.00           70.00
    BDZ...........................  Pediatric Care NEC..............           64.00          119.00          126.00
    ----------------------------------------------------------------------------------------------------------------
                                                   E. Orthopaedic Care                                              
    ----------------------------------------------------------------------------------------------------------------
    BEA...........................  Orthopaedic.....................           83.00          153.00          164.00
    BEB...........................  Cast............................           45.00           82.00           88.00
    BEC...........................  Hand Surgery....................           38.00           70.00           75.00
    BEE...........................  Orthotic Laboratory.............           59.00          110.00          117.00
    BEF...........................  Podiatry........................           49.00           91.00           97.00
    BEZ...........................  Chiropractic....................           21.00           38.00           40.00
    ----------------------------------------------------------------------------------------------------------------
                                        F. Psychiatric and/or Mental Health Care                                    
    ----------------------------------------------------------------------------------------------------------------
    BFA...........................  Psychiatry......................           97.00          179.00          191.00
    BFB...........................  Psychology......................           71.00          132.00          141.00
    BFC...........................  Child Guidance..................           59.00          109.00          117.00
    BFD...........................  Mental Health...................           80.00          147.00          157.00
    BFE...........................  Social Work.....................           80.00          149.00          159.00
    BFF...........................  Substance Abuse.................           62.00          115.00          123.00
    ----------------------------------------------------------------------------------------------------------------
                                         G. Family Practice/Primary Medical Care                                    
    ----------------------------------------------------------------------------------------------------------------
    BGA...........................  Family Practice.................           67.00          124.00          132.00
    BHA...........................  Primary Care....................           64.00          118.00          126.00
    BHB...........................  Medical Examination.............           59.00          109.00          117.00
    BHC...........................  Optometry.......................           42.00           77.00           82.00
    BHD...........................  Audiology.......................           30.00           55.00           58.00
    BHE...........................  Speech Pathology................           81.00          149.00          159.00
    BHF...........................  Community Health................           41.00           75.00           80.00
    BHG...........................  Occupational Health.............           59.00          108.00          115.00
    BHH...........................  TRICARE Outpatient..............           42.00           78.00           83.00
    BHI...........................  Immediate Care..................           82.00          152.00          162.00
    BHZ...........................  Primary Care NEC................           43.00           79.00           84.00
    ----------------------------------------------------------------------------------------------------------------
                                                H. Emergency Medical Care                                           
    ----------------------------------------------------------------------------------------------------------------
    BIA...........................  Emergency Medical...............          107.00          198.00          211.00
    ----------------------------------------------------------------------------------------------------------------
                                                 I. Flight Medical Care                                             
    ----------------------------------------------------------------------------------------------------------------
    BJA...........................  Flight Medicine.................           85.00          157.00          167.00
    ----------------------------------------------------------------------------------------------------------------
                                                J. Underseas Medical Care                                           
    ----------------------------------------------------------------------------------------------------------------
    BKA...........................  Underseas Medicine..............           32.00           58.00           62.00
    ----------------------------------------------------------------------------------------------------------------
                                               K. Rehabilitative Services                                           
    ----------------------------------------------------------------------------------------------------------------
    BLA...........................  Physical Therapy................           29.00           54.00           57.00
    BLB...........................  Occupational Therapy............           53.00           98.00          104.00
    ----------------------------------------------------------------------------------------------------------------
    
    
    [[Page 54135]]
    
    III. Other Rates and Charges \1\ \2\ Per Visit
    
    ----------------------------------------------------------------------------------------------------------------
                                                                       International    Interagency                 
                                                                         Military        and other                  
            MEPRS code \4\                  Clinical service            Education &   Federal agency   Other  (Full/
                                                                         Training        sponsored     Third party) 
                                                                          (IMET)         patients                   
    ----------------------------------------------------------------------------------------------------------------
    FBI...........................  A. Immunization.................          $10.00          $19.00          $20.00
    DGC...........................  B. Hyperbaric Chamber \5\.......          180.00          333.00          355.00
                                    C. Ambulatory Procedure Visit             376.00          691.00          737.00
                                     (APV) \6\.                                                                     
                                    D. Family Member Rate (formerly            10.20  ..............  ..............
                                     Military Dependents Rate).                                                     
    ----------------------------------------------------------------------------------------------------------------
    
    E. Reimbursement Rates For Drugs Requested By Outside Providers \7\
        The FY98 drug reimbursement rates for drugs are for prescriptions 
    requested by outside providers and obtained at a Military Treatment 
    Facility. The rates are established based on the cost of the particular 
    drugs provided. Final rule of 32 CFR part 220, estimated to be 
    published October 1, 1997, will eliminate the high cost ancillary 
    services' dollar threshold and the associated term ``high cost 
    ancillary service.'' In anticipation of that change, the phrase ``high 
    cost ancillary service'' has been replaced with the phrase ``ancillary 
    services requested by an outside provider.'' The list of drug 
    reimbursement rates is too large to include here. These rates are 
    available on request from OASD (Health Affairs)--see Tab N for the 
    point of contact.
    F. Reimbursement Rates for Ancillary Services Requested By Outside 
    Providers \8\
        Final rule of 32 CFR part 220, estimated to be published October 1, 
    1997, will eliminate the high cost ancillary services' dollar threshold 
    and the associated term ``high cost ancillary service.'' In 
    anticipation of that change, the phrase ``high cost ancillary service'' 
    has been replaced with the phrase ``ancillary services requested by an 
    outside provider.'' The list of FY98 rates for ancillary services 
    requested by outside providers and obtained at a Military Treatment 
    Facility is too large to include here. These rates are available on 
    request from OASD(Health Affairs)--see Tab N for the point of contact.
    G. Elective Cosmetic Surgery Procedures and Rates
    
    ----------------------------------------------------------------------------------------------------------------
                                        International    Current Procedural                                         
       Cosmetic surgery procedure      Classification     Terminology (CPT)     FY98 charge \10\        Amount of   
                                      Diseases (ICD-9)           \9\                                      charge    
    ----------------------------------------------------------------------------------------------------------------
    Mammaplasty....................  85.50, 85.32,       19325, 19324,       Inpatient Surgical      (a b c)        
                                      85.31.              19318.              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Mastopexy......................  85.60.............  19316.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Facial Rhytidectomy............  86.82, 86.22......  15824.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Blepharoplasty.................  08.70, 08.44......  15820, 15821,       Inpatient Surgical      (a b c)        
                                                          15822, 15823.       Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Mentoplasty (Augmentation        76.68, 76.67......  21208, 21209......  Inpatient Surgical      (a b c)        
     Reduction).                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Abdominoplasty.................  86.83.............  15831.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Lipectomy suction per region     86.83.............  15876, 15877,       Inpatient Surgical      (a b c)        
     \11\.                                                15878, 15879.       Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Rhinoplasty....................  21.87, 21.86......  30400, 30410......  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Scar Revisions beyond CHAMPUS..  86.84.............  1578__............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Mandibular or Maxillary          76.41.............  21194.............  Inpatient Surgical      (a b c)        
     Repositioning.                                                           Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Minor Skin Lesions \12\........  86.30.............  1578__............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Dermabrasion...................  86.25.............  15780.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Hair Restoration...............  86.64.............  15775.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Removing Tattoos...............  86.25.............  15780.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Chemical Peel..................  86.24.............  15790.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Arm/Thigh Dermolipectomy.......  86.83.............  1583__............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    Brow Lift......................  86.3..............  15839.............  Inpatient Surgical      (a b c)        
                                                                              Care Per Diem or APV                  
                                                                              or applicable                         
                                                                              Outpatient Clinic                     
                                                                              Rate.                                 
    ----------------------------------------------------------------------------------------------------------------
    
    
    [[Page 54136]]
    
    H. Dental Rate \13\ Per Procedure
    
    ----------------------------------------------------------------------------------------------------------------
                                                                       International    Interagency                 
                                                                         military        and other                  
            MEPRS code \4\                  Clinical service           education and  federal agency   Other  (Full/
                                                                         training        sponsored     third party) 
                                                                          (IMET)         patients                   
    ----------------------------------------------------------------------------------------------------------------
                                    oDental Services................          $35.00         $101.00         $106.00
                                    ADA code and DoD established                                                    
                                     weight.                                                                        
    ----------------------------------------------------------------------------------------------------------------
    
    I. Ambulance Rate \14\ Per Visit
    
    ----------------------------------------------------------------------------------------------------------------
                                                                       International  nteragency and                
                                                                         military      other federal                
            MEPRS code \4\                  Clinical service           education and      agency       Other  (Full/
                                                                         training        sponsored     Third party) 
                                                                          (IMET)         patients                   
    ----------------------------------------------------------------------------------------------------------------
    FEA...........................  Ambulance.......................          $32.00          $60.00          $64.00
    ----------------------------------------------------------------------------------------------------------------
    
    J. Laboratory and Radiology Services Requested by an Outside Provider 
    \8\ Per Procedure
    
    ----------------------------------------------------------------------------------------------------------------
                                                                       International   nteragency &                 
                                                                         military      other federal                
            MEPRS code \4\                  Clinical service            education &       agency       Other (full/ 
                                                                         training        sponsored     third party) 
                                                                          (IMET)         patients                   
    ----------------------------------------------------------------------------------------------------------------
                                    Laboratory procedures requested            $9.00          $13.00          $14.00
                                     by an outside provider CPT-4                                                   
                                     Weight Multiplier.                                                             
                                    Radiology procedures requested             23.00           35.00           37.00
                                     by an outside provider CPT-4                                                   
                                     Weight Multiplier.                                                             
    ----------------------------------------------------------------------------------------------------------------
    
    K. AirEvac Rate \15\ Per Visit
    
    ----------------------------------------------------------------------------------------------------------------
                                                                       International    Interagency                 
                                                                         military        and other                  
            MEPRS code \4\                  Clinical service           education and  federal agency   Other  (Full/
                                                                         training        sponsored     third party) 
                                                                          (IMET)         patients                   
    ----------------------------------------------------------------------------------------------------------------
                                    AirEvac Services--Ambulatory....         $113.00         $209.00         $223.00
                                    AirEvac Services--Litter........          323.00          598.00          638.00
    ----------------------------------------------------------------------------------------------------------------
    
    Notes on Cosmetic Surgery Charges
    
        a Per diem charges for inpatient surgical care 
    services are listed in section I.B. (See notes 9 through 11, below, 
    for further details on reimbursable rates.)
        b Charges for ambulatory procedure visits (formerly 
    same day surgery) are listed in section III.C. (See notes 9 through 
    11, below, for further details on reimbursable rates.) The APV rate 
    is used if the elective cosmetic surgery is performed in an 
    ambulatory procedure unit (APU).
        c Charges for outpatient clinic visits are listed in 
    section II.A-K. The outpatient clinic rate is not used for services 
    provided in an APU. The APV rate should be used in these cases.
    
    Notes on Reimbursable Rates
    
        1 Percentages can be applied when preparing bills for 
    both inpatient and outpatient services. Pursuant to the provisions 
    of 10 U.S.C. 1095, the inpatient Diagnosis Related Groups and 
    inpatient per diem percentages are 96 percent hospital and 4 percent 
    professional charges. The outpatient per visit percentages are 88 
    percent outpatient services and 12 percent professional charges.
        2 DoD civilian employees located in overseas areas 
    shall be rendered a bill when services are performed. Payment is due 
    60 days from the date of the bill.
        3 The cost per DRG (Diagnosis Related Group) is based 
    on the inpatient full reimbursement rate per hospital discharge, 
    weighted to reflect the intensity of the principal and secondary 
    diagnoses, surgical procedures, and patient demographics involved. 
    The adjusted standardized amounts (ASA) per Relative Weighted 
    Product (RWP) for use in the direct care system is comparable to 
    procedures used by the Health Care Financing Administration (HCFA) 
    and the Civilian Health and Medical Program for the Uniformed 
    Services (CHAMPUS). These expenses include all direct care expenses 
    associated with direct patient care. The average cost per RWP for 
    large urban, other urban/rural, and overseas will be published 
    annually as an adjusted standardized amount (ASA) and will include 
    the cost of inpatient professional services. The DRG rates will 
    apply to reimbursement from all sources, not just third party 
    payers.
        4 The Medical Expense and Performance Reporting 
    System (MEPRS) code is a three digit code which defines the summary 
    account and the subaccount within a functional category in the DoD 
    medical system. MEPRS codes are used to ensure that consistent 
    expense and operating performance data is reported in the DoD 
    military medical system. An example of the MEPRS hierarchical 
    arrangement follows: Outpatient Care (Functional Category), B (MEPRS 
    Code), Medical Care (Summary Account), BA (MEPRS Code), Internal 
    Medicine (Subaccount), BAA (MEPRS Code).
        5 Hyperbaric services charges shall be based on hours 
    of service in 15 minute increments. The rates listed in section 
    III.B. are for 60 minutes or 1 hour of service. Providers shall 
    calculate the charges based on the number of hours (and/or fractions 
    of an hour) of service. Fractions of an hour shall be rounded to the 
    next 15 minute increment (e.g., 31 minutes shall be charged as 45 
    minutes).
        6 Ambulatory Procedure Visit (APV) is defined in DOD 
    Instruction 6025.8, September 23, 1996, as immediate (day of 
    procedure) pre-procedure and immediate post-procedure care requiring 
    an unusual degree of intensity and provided in an ambulatory 
    procedure
    
    [[Page 54137]]
    
    unit (APU). Care is required in the facility for less than 24 hours. 
    This rate is also used for elective cosmetic surgery performed in an 
    APU.
        7 Prescription services requested by outside 
    providers (physicians, dentists, etc.) are relevant to the Third 
    Party Collection Program. Third party payers (such as insurance 
    companies) shall be billed for prescription services when 
    beneficiaries who have medical insurance obtain medications from a 
    Military Treatment Facility (MTF) that are prescribed by providers 
    external to the MTF. Eligible beneficiaries (family members or 
    retirees with medical insurance) are not personally liable for this 
    cost and shall not be billed by the MTF. Medical Services Account 
    (MSA) patients, who are not beneficiaries as defined in 10 U.S.C. 
    1074 and 1076, are charged at the ``Other'' rate if they are seen by 
    an outside provider and come to the MTF for prescription services. 
    The standard cost of medications ordered by an outside provider 
    includes the cost of the drugs plus a dispensing fee per 
    prescription. The prescription cost is calculated by multiplying the 
    number of units (tablets, capsules, etc.) by the unit cost and 
    adding a $5.00 dispensing fee per prescription. Final rule of 32 CFR 
    part 220, estimated to be published October 1, 1997, will eliminate 
    the high cost ancillary services' dollar threshold (by changing it 
    from $25 to $0) and the associated term ``high cost ancillary 
    service.'' In anticipation of that change, the phrase ``high cost 
    ancillary service'' has been replaced with the phrase ``ancillary 
    services requested by an outside provider.'' The elimination of the 
    threshold ipso facto eliminates the bundling of costs whereby a 
    patient was billed if the total ancillary services costs in a day 
    (defined as 0001 hours to 2400 hours) exceeded $25.00.
        8 Charges for ancillary services requested by an 
    outside provider (physicians, dentists, etc.) are relevant to the 
    Third Party Collection Program. Third party payers (such as 
    insurance companies) shall be billed for ancillary services when 
    beneficiaries who have medical insurance obtain services from the 
    MTF that are prescribed by providers external to the MTF. Laboratory 
    and Radiology procedure costs are calculated using the Physicians' 
    Current Procedural Terminology (CPT)-4 Report weight multiplied by 
    either the laboratory or radiology multiplier (section III.J). 
    Eligible beneficiaries (family members or retirees with medical 
    insurance) are not personally liable for this cost and shall not be 
    billed by the MTF. MSA patients, who are not beneficiaries as 
    defined by 10 U.S.C. 1074 and 1076, are charged at the ``Other'' 
    rate if they are seen by an outside provider and come to the MTF for 
    services. Final rule of 32 CFR Part 220, estimated to be published 
    October 1, 1997, will eliminate the high cost ancillary services' 
    dollar threshold (by changing it from $25 to $0) and the associated 
    term ``high cost ancillary service.'' In anticipation of that 
    change, the phrase ``high cost ancillary service'' has been replaced 
    with the phrase ``ancillary services requested by an outside 
    provider.'' The elimination of the threshold ipso facto eliminates 
    the bundling of costs whereby a patient was billed if the total 
    ancillary services costs in a day (defined as 0001 hours to 2400 
    hours) exceeded $25.00.
        9 The attending physician is to complete the CPT-4 
    code to indicate the appropriate procedure followed during cosmetic 
    surgery. The appropriate rate will be applied depending on the 
    treatment modality of the patient: Ambulatory procedure visit, 
    outpatient clinic visit or inpatient surgical care services.
        10 Family members of active duty personnel, retirees 
    and their family members, and survivors shall be charged elective 
    cosmetic surgery rates. Elective cosmetic surgery procedure 
    information is contained in Section III G. The patient shall be 
    charged the rate as specified in the FY98 reimbursable rates for an 
    episode of care. The charges for elective cosmetic surgery are at 
    the full reimbursement rate (designated as the ``Other'' rate) for 
    inpatient per diem surgical care services in section I.B., 
    ambulatory procedure visits as contained in section III.C, or the 
    appropriate outpatient clinic rate in section II A-K. The patient is 
    responsible for the cost of the implant(s) and the prescribed 
    cosmetic surgery rate. NOTE: The implants and procedures used for 
    the augmentation mammaplasty are in compliance with Federal Drug 
    Administration guidelines.
        11 Each regional lipectomy shall carry a separate 
    charge. Regions include head and neck, abdomen, flanks, and hips.
        12 These procedures are inclusive in the minor skin 
    lesions. However, CHAMPUS separates them as noted here. All charges 
    shall be for the entire treatment, regardless of the number of 
    visits required.
        13 Dental service rates are based on a dental rate 
    multiplier times the American Dental Association (ADA) code and the 
    DoD established weight for that code.
        14 Ambulance charges shall be based on hours of 
    service in 15 minute increments. The rates listed in section III.I 
    are for 60 minutes or 1 hour of service. Providers shall calculate 
    the charges based on the number of hours (and/or fractions of an 
    hour) that the ambulance is logged out on a patient run. Fractions 
    of an hour shall be rounded to the next 15 minute increment (e.g., 
    31 minutes shall be charged as 45 minutes).
        15 Air in-flight medical care reimbursement charges 
    are determined by the status of the patient (ambulatory or litter) 
    and are per patient. The charges are billed only by the Air Force 
    Global Patient Movement Requirement Center (GFMRC).
    
    2. Department of Health and Human Services
    
        For the Department of Health and Human Services, Indian Health 
    Service, effective October 1, 1997 and thereafter:
    
                           Hospital Care Inpatient Day                      
                                                                            
    General Medical Care...............  Alaska....................   $1,702
                                         Rest of the United States.    1,049
                                                                            
                          Outpatient Medical Treatment                      
                                                                            
    Outpatient Visit...................  Alaska....................      340
                                         Rest of the United States.      209
                                                                            
    
    3. Department of Veterans Affairs
    
        For the Department of Veterans Affairs, effective October 1, 1997 
    and thereafter:
    
    ------------------------------------------------------------------------
                                                Tortiously      Interagency 
                                               liable rates        rates    
    ------------------------------------------------------------------------
                     Hospital Care, Rates Per Inpatient Day                 
    ------------------------------------------------------------------------
    General Medicine:                                                       
        Total...............................           $1208           $1098
            Physician.......................             145  ..............
            Ancillary.......................             315  ..............
            Nursing, Room, and Board........             748  ..............
    Neurology:                                                              
        Total...............................            1154            1042
            Physician.......................             169  ..............
            Ancillary.......................             305  ..............
    
    [[Page 54138]]
    
                                                                            
            Nursing, Room, and Board........             680  ..............
    Rehabilitation Medicine:                                                
      Total.................................             808             729
            Physician.......................              92  ..............
            Ancillary.......................             247  ..............
            Nursing, Room, and Board........             469  ..............
    Blind Rehabilitation:                                                   
      Total.................................             957             873
            Physician.......................              77  ..............
            Ancillary.......................             475  ..............
            Nursing, Room, and Board........             405  ..............
    Spinal Cord Injury:                                                     
      Total.................................             886             801
            Physician.......................             110  ..............
            Ancillary.......................             223  ..............
            Nursing, Room, and Board........             553  ..............
    Surgery:                                                                
        Total...............................            2079            1904
            Physician.......................             229  ..............
            Ancillary.......................             631  ..............
            Nursing, Room, and Board........            1219  ..............
    General Psychiatry:                                                     
        Total...............................             557             518
            Physician.......................              54  ..............
            Ancillary.......................              91  ..............
            Nursing, Room, and Board........             432  ..............
    Substance Abuse (Alcohol and Drug                                       
     Treatment):                                                            
        Total...............................             333             300
            Physician.......................              32  ..............
            Ancillary.......................              77  ..............
            Nursing, Room, and Board........             224  ..............
    Intermediate Medicine:                                                  
        Total...............................             396             356
            Physician.......................              19  ..............
            Ancillary.......................              58  ..............
            Nursing, Room, and Board........             319  ..............
    ------------------------------------------------------------------------
                         Nursing Home Care, Rates Per Day                   
    ------------------------------------------------------------------------
    Nursing Home Care:                                                      
        Total...............................             299             270
            Physician.......................               9  ..............
            Ancillary.......................              40  ..............
            Nursing Room, and Board.........             250  ..............
    ------------------------------------------------------------------------
                     Outpatient Medical and Dental Treatment                
    ------------------------------------------------------------------------
    Outpatient Visit:                                                       
        Total...............................             229             211
    Emergency Dental........................             143             127
    Outpatient Visit Prescription Filled....              25              25
    ------------------------------------------------------------------------
    
        For the period beginning October 1, 1997, the rates prescribed 
    herein superseded those established by the Director of the Office of 
    Management and Budget, October 31, 1996 (61 FR 56360).
    Franklin D. Raines,
    Director, Office of Management and Budget.
    [FR Doc. 97-27629 Filed 10-16-97; 8:45 am]
    BILLING CODE 3110-01-P
    
    
    

Document Information

Published:
10/17/1997
Department:
Management and Budget Office
Entry Type:
Notice
Document Number:
97-27629
Pages:
54131-54138 (8 pages)
PDF File:
97-27629.pdf