[Federal Register Volume 60, Number 191 (Tuesday, October 3, 1995)]
[Notices]
[Pages 51779-51780]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-24577]
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DEPARTMENT OF DEFENSE
Office of the Secretary
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); FY96 DRG Updates
AGENCY: Office of the Secretary, DoD.
ACTION: Notice of DRG revised rates.
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SUMMARY: This notice provides the updated adjusted standardized
amounts, DRG relative weights, outlier thresholds, and beneficiary
cost-share per diem rates to be used for FY 1996 under the CHAMPUS DRG-
based payment system. It also describes the changes made to the CHAMPUS
DRG-based payment system in order to conform to changes made to the
Medicare Prospective Payment System (PPS).
EFFECTIVE DATES: The rates and weights and Medicare PPS changes which
affect the CHAMPUS DRG-based payment system contained in this notice
are effective for admissions occurring on or after October 1, 1995.
ADDRESSES: Office of the Civilian Health and Medical Program of the
Uniformed Services (OCHAMPUS), Program Development Branch, Aurora, CO
80045-6900.
For copies of the Federal Register containing this notice, contact
the Superintendent of Documents, U.S. Government Printing Office,
Washington, D.C. 20402, (202) 783-3238. The charge for the Federal
Register is $1.50 for each issue payable by check or money order to the
Superintendent of Documents.
FOR FURTHER INFORMATION CONTACT: Marty Maxey, Program Development
Branch, OCHAMPUS, telephone (303) 361-1227.
To obtain copies of this document, see the ADDRESSES section above.
Questions regarding payment of specific claims under the CHAMPUS DRG-
based payment system should be addressed to the appropriate CHAMPUS
contractor.
SUPPLEMENTARY INFORMATION: The final rule published on September 1,
1987 (52 FR 32992) set forth the basic procedures used under the
CHAMPUS DRG-based payment system. This was subsequently amended by
final rules published August 31, 1988 (53 FR 33461), October 21, 1988
(53 FR 41331), December 16, 1988 (53 FR 50515), May 30, 1990 (55 FR
21863), and October 22, 1990 (55 FR 42560).
An explicit tenet of these final rules, and one based on the
statute authorizing use of DRGs by CHAMPUS, is that the CHAMPUS DRG-
based payment system is modeled on the Medicare PPS, and that, whenever
practicable, the CHAMPUS system will follow the same rules that apply
to the Medicare PPS. HCFA publishes these changes annually in the
Federal Register and discusses in detail the impact of the changes.
In addition, this notice updates the rates and weights in
accordance with our previous final rules. The actual changes we are
making, along with a description of their relationship to the Medicare
PPS, are detailed below.
I. Medicare PPS Changes Which Affect the CHAMPUS DRG-Based Payment
System
Following is a discussion of the changes the Health Care Financing
Administration (HCFA) has made to the Medicare PPS which affect the
CHAMPUS DRG-based payment system.
A. DRG Classifications
Under both the Medicare PPS and the CHAMPUS DRG-based payment
system, cases are classified into the appropriate DRG by a Grouper
program. The Grouper classifies each case into a DRG on the basis of
the diagnosis and procedure codes and demographic information (that is,
sex, age, and discharge status). The Grouper used for the CHAMPUS DRG-
based payment system is the same as the current Medicare Grouper with
two modifications. The CHAMPUS system has replaced Medicare DRG 435
with two age-based DRGs (900 and 901), and we have implemented thirty-
four (34) neonatal DRGs in place of Medicare DRGs 385 through 390. For
admissions occurring on or after October 1, 1995 the CHAMPUS grouper
hierarchy logic has been changed so the age split (age (<29 days)="" and="" assignments="" to="" mdc="" 15="" occur="" before="" assignment="" of="" the="" premdc="" drgs.="" this="" will="" result="" in="" all="" neonate="" tracheostomies="" and="" organ="" transplants="" to="" be="" grouped="" to="" mdc="" 15="" drgs="" and="" not="" to="" drgs="" 480-483="" or="" 495.="" grouping="" for="" all="" other="" drgs="" under="" the="" champus="" system="" is="" identical="" to="" the="" medicare="" pps.="" for="" fy="" 1995,="" hcfa="" will="" implement="" a="" number="" of="" classification="" changes,="" including="" surgical="" hierarchy="" changes,="" revisions="" to="" the="" major="" problem="" diagnosis="" list,="" and="" refinements="" to="" the="" complications="" and="" comorbidities="" (cc)="" list.="" the="" champus="" grouper="" will="" incorporate="" all="" changes="" made="" to="" the="" medicare="" grouper.="" b.="" wage="" index="" and="" medicare="" geographic="" classification="" review="" board="" guidelines="" champus="" will="" continue="" to="" use="" the="" same="" wage="" index="" amounts="" used="" for="" the="" medicare="" pps.="" in="" addition,="" champus="" will="" duplicate="" all="" changes="" with="" regard="" to="" the="" wage="" index="" for="" specific="" hospitals="" which="" are="" redesignated="" by="" the="" medicare="" geographic="" classification="" review="" board.="" c.="" hospital="" market="" basket="" we="" will="" update="" the="" adjusted="" standardized="" amounts="" according="" to="" the="" final="" updated="" hospital="" market="" basket="" used="" for="" the="" medicare="" pps="" according="" to="" hcfa's="" september="" 1="" final="" rule.="" d.="" outlier="" payments="" champus="" is="" adopting="" the="" hcfa="" outlier="" thresholds="" for="" fy96.="" the="" long-="" stay="" threshold="" shall="" equal="" the="" lesser="" of="" 3.0="" standard="" deviations="" or="" 23="" days="" above="" the="" drg's="" geometric="" los.="" long-stay="" outliers="" will="" be="" reimbursed="" the="" drg-based="" amount="" plus="" 44="" percent="" of="" the="" per="" diem="" rate="" for="" the="" drg="" for="" each="" covered="" day="" of="" care="" beyond="" the="" long-stay="" outlier="" threshold.="" the="" cost="" outlier="" will="" be="" reimbursed="" the="" drg-based="" amount="" plus="" 80="" percent="" of="" the="" standardized="" costs="" exceeding="" the="" threshold.="" the="" cost="" outlier="" threshold="" shall="" be="" the="" drg="" payment="" (wage-adjusted="" but="" prior="" to="" adjustment="" for="" indirect="" medical="" education)="" plus="" a="" flat="" rate="" of="" $13,800.="" e.="" capital-related="" costs="" effective="" for="" discharges="" occurring="" on="" or="" after="" october="" 1,="" 1995,="" hcfa="" will="" increase="" its="" inpatient="" capital-related="" prospective="" payment="" rate.="" the="" major="" factor="" contributing="" to="" the="" increase="" is="" the="" expiration="" of="" the="" budget-neutrality="" requirement="" that="" mandated="" estimated="" payments="" for="" capital="" costs="" equal="" 90%="" of="" the="" amount="" that="" would="" have="" been="" payable="" each="" year="" from="" fy="" 1992="" through="" fy="" 1995="" on="" a="" reasonable="" cost="" basis.="" since="" champus="" pays="" for="" capital-related="" costs="" on="" a="" retrospective="" basis="" based="" on="" actual="" costs="" instead="" of="" prospectively="" like="" medicare,="" we="" will="" reimburse="" 100%="" of="" capital-related="" costs="" for="" champus="" days="" occurring="" on="" or="" after="" october="" 1,="" 1995.="" f.="" determination="" of="" number="" of="" beds="" for="" purposes="" of="" calculating="" the="" indirect="" medical="" education="" adjustment="" we="" will="" clarify="" our="" bed="" counting="" policy.="" we="" will="" specify="" that="" beds="" or="" bassinets="" in="" a="" healthy,="" or="" regular,="" baby="" nursery="" are="" excluded="" from="" the="" bed="" count="" [[page="" 51780]]="" for="" purposes="" of="" calculating="" the="" indirect="" medical="" education="" adjustment.="" g.="" payment="" for="" transfer="" cases="" champus="" is="" adopting="" hcfa's="" graduated="" per="" diem="" payment="" methodology="" for="" transfer="" cases.="" under="" this="" payment="" methodology,="" champus="" will="" pay="" transferring="" hospitals,="" twice="" the="" per="" diem="" amount="" for="" the="" first="" day="" of="" any="" transfer="" stay="" plus="" the="" per="" diem="" amount="" for="" each="" of="" the="" remaining="" days="" before="" transfer,="" up="" to="" the="" full="" drg="" amount.="" for="" neonatal="" cases,="" other="" than="" normal="" newborns,="" the="" transferring="" hospital="" will="" be="" paid="" twice="" the="" per="" diem="" amount="" for="" the="" first="" day="" of="" any="" transfer="" stay="" plus="" 125="" percent="" of="" the="" per="" diem="" rate="" for="" all="" remaining="" days="" before="" transfer,="" up="" to="" the="" full="" drg="" amount.="" this="" change="" will="" allow="" hospitals="" to="" be="" compensated="" more="" appropriately="" for="" the="" treatment="" they="" furnish="" to="" patients="" before="" transfer.="" transferring="" hospitals="" will="" continue="" to="" be="" paid="" in="" full="" for="" discharges="" classified="" into="" drg="" 456="" (burns,="" transferred="" to="" another="" acute="" care="" facility)="" or="" drg="" 601="" (neonate,="" transferred="" less="" than="" or="" equal="" to="" 4="" days="" old).="" h.="" effect="" of="" change="" of="" ownership="" on="" exclusion="" of="" long-term="" care="" hospitals="" champus="" is="" adopting="" hcfa's="" new="" requirements="" for="" certain="" long-term="" care="" hospitals="" excluded="" from="" the="" pps.="" champus="" will="" clarify="" its="" policy="" by="" specifying="" that="" if="" a="" hospital="" undergoes="" a="" change="" of="" ownership="" at="" the="" start="" of="" a="" cost="" reporting="" period="" or="" at="" any="" time="" within="" the="" preceding="" 6="" months,="" the="" hospital="" may="" be="" excluded="" from="" the="" prospective="" payment="" system="" as="" a="" long-term="" care="" hospital="" for="" a="" cost="" reporting="" period="" if,="" for="" the="" 6="" months="" immediately="" preceding="" the="" start="" of="" the="" period="" (including="" time="" before="" the="" change="" of="" ownership),="" the="" hospital="" has="" the="" required="" average="" length="" of="" stay,="" continuously="" operated="" as="" a="" hospital,="" and="" continuously="" participated="" as="" a="" hospital="" in="" medicare.="" ii.="" cost-to-charge="" ratio="" for="" fy="" 1996,="" the="" cost-to-charge="" ratio="" used="" for="" the="" champus="" drg-="" based="" payment="" system="" will="" be="" 0.6003="" which="" is="" increased="" to="" 0.6103="" to="" account="" for="" bad="" debts.="" this="" shall="" be="" used="" to="" calculate="" the="" adjusted="" standardized="" amounts="" and="" to="" calculate="" cost="" outlier="" payments,="" except="" for="" children's="" hospitals.="" for="" children's="" hospital="" cost="" outliers,="" the="" cost-="" to-charge="" ratio="" used="" is="" 0.6691.="" iii.="" updated="" rates="" and="" weights="" tables="" 1="" and="" 2="" provide="" the="" rates="" and="" weights="" to="" be="" used="" under="" champus="" drg-based="" payment="" system="" during="" fy="" 1996="" and="" which="" are="" a="" result="" of="" the="" changes="" described="" above.="" the="" implementing="" regulations="" for="" the="" champus="" drg-based="" payment="" system="" are="" in="" 32="" cfr="" part="" 199.="" iv.="" elimination="" of="" physician="" attestation="" form="" champus="" is="" adopting="" medicare's="" process="" for="" eliminating="" the="" physician="" attestation="" form="" that="" requires="" doctors="" to="" certify="" the="" accuracy="" of="" all="" diagnoses="" and="" procedures="" before="" submitting="" claims="" for="" payment="" to="" champus.="" editorial="" note.--this="" table="" will="" not="" appear="" in="" the="" code="" of="" federal="" regulations.="" table="" 1--national="" urban="" and="" rural="" adjusted="" standardized="" amounts,="" labor/="" nonlabor,="" and="" cost-share="" per="" diem="" the="" following="" summary="" provides="" the="" adjusted="" standardized="" amounts="" and="" the="" cost-share="" per="" diem="" for="" beneficiaries="" other="" than="" dependents="" of="" active-duty="" members.="" the="" adjusted="" standardized="" amounts="" are="" effective="" for="" admissions="" occurring="" on="" or="" after="" october="" 1,="" 1995.="" national="" large="" urban="" adjusted:="" standardized="" amount.....................................="" $="" ,="" .="" labor="" portion.........................................="" $="" ,="" .="" nonlabor="" portion......................................="" $="" ,="" .="" national="" other="" areas:="" standardized="" amount.....................................="" $="" ,="" .="" labor="" protion.........................................="" $="" ,="" .="" nonlabor="" portion......................................="" $="" ,="" .="" the="" cost-share="" per="" diem="" is="" effective="" for="" inpatient="" days="" of="" care="" occurring="" on="" or="" after="" october="" 1,="" 1995.="" cost-share="" per="" diem="" for="" beneficiaries="" other="" than="" dependents="" of="" active-duty="" members........................="" $="" .="" dated:="" september="" 28,="" 1995.="" l.m.="" bynum,="" alterate="" osd="" federal="" register="" liaison="" officer,="" department="" of="" defense.="" [fr="" doc.="" 95-24577="" filed="" 10-2-95;="" 8:45="" am]="" billing="" code="" 5000-04-m="">