[Federal Register Volume 64, Number 210 (Monday, November 1, 1999)]
[Notices]
[Pages 58862-58870]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-28115]
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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 FY 2000 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.E) and
the rates for Ancillary Services Requested by Outside Providers
(Section III.F) 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, 1999. Pharmacy rates are updated on an as-needed basis.
2. Health and Human Services
The development of FY 2000 tortiously liable rates for Indian
Health Service health facilities incorporate a refinement in the method
used in the development of the FY 1999 rates. This year the Department
has elected to use Medicare cost reports to develop the FY 2000
tortiously liable rates.
The obligations for the Indian Health Service hospitals
participating in the cost report project were identified and combined
with applicable obligations for area offices costs and headquarters
costs. The hospital obligations were summarized for each major cost
center providing medical services and distributed between inpatient and
outpatient. Total inpatient costs and outpatient costs were then
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 costs were incorporated to conform
to requirements set forth in OMB Circular A-25.
In addition, the obligations for each cost center include
obligations from certain other accounts, such as Medicare and Medicaid
collections and Contract Health fund, that were used to support direct
program operations. Obligations were excluded for certain cost centers
that primarily support workloads outside of the directly operated
hospitals or clinics (public health nursing, public health nutrition,
health education).
These obligations are not a part of the traditional cost of
hospital operations and do not contribute directly to the inpatient and
outpatient visit workload. Overall, these rates reflect a more accurate
indication of the cost of care in the Department's hospital facilities.
Separate rates per inpatient day and outpatient visit were computed
for
[[Page 58863]]
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 tortiously liable rates shown will be used to seek recovery for
VA medical care or services provided or furnished to persons in the
following situations: tort feasor, humanitarian emergency, VA employee,
family member, ineligible person, and allied beneficiary.
The interagency rates shown will 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. When the 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.
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.
1. Department of Defense
For the Department of Defense, effective October 1, 1999 and
thereafter:
Medical and Dental Services
Fiscal Year 2000--Inpatient, Outpatient and Other Rates and Charges
I. Inpatient Rates \1\ \2\
----------------------------------------------------------------------------------------------------------------
International Interagency
military and other
Per inpatient day education and Federal agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
A. Burn Center.................................................. $3,080.00 $5,529.00 $5,840.00
B. Surgical Care Services (Cosmetic Surgery).................... 1,411.00 2,533.00 2,675.00
C. All Other Inpatient Services (Based on Diagnosis Related
Groups (DRG) \3\)
----------------------------------------------------------------------------------------------------------------
1. FY 2000 Direct Care Inpatient Reimbursement Rates
----------------------------------------------------------------------------------------------------------------
Other (full/
Adjusted standard amount IMET Interagency third party)
----------------------------------------------------------------------------------------------------------------
Large Urban..................................................... $2,921.00 $5,498.00 $5,775.00
Other Urban/Rural............................................... 3,236.00 6,532.00 6,883.00
Overseas........................................................ 3,606.00 8,520.00 8,941.00
----------------------------------------------------------------------------------------------------------------
2. Overview
The FY 2000 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.
a. The cost to be recovered is DoD's cost for medical services
provided in the non-teaching 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 2.3446. (DRG statistics
shown are from FY 1998).
c. The DoD adjusted standardized amount to be charged is $5,775
(i.e., the third party rate as shown in the table).
d. DoD cost to be recovered at a non-teaching hospital with area
wage index of 1.0 is the RWP factor (2.3446) in 3.b., above, multiplied
by the amount ($5,775) in 3.c., above.
[[Page 58864]]
e. Cost to be recovered is $13,540
Figure 1.--Third Party Billing Examples
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Arithmetic Geometric Short stay Long stay
DRG No. DRG description DRG weight mean LOS mean LOS threshold threshold
----------------------------------------------------------------------------------------------------------------
020.............. Nervous System 2.3446 8.1 5.7 1 29
Infection Except Viral
Meningitis.
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Area wage IME
Hospital Location rate index adjustment Group ASA Applied ASA
----------------------------------------------------------------------------------------------------------------
Non-teaching Hospital............. Large Urban......... 1.0 1.0 $5,775 $5,775
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Relative weighted product TPC
Patient Length of stay Days above -------------------------------------------------------
threshold Inlier * Outlier * * Total Amount * * *
----------------------------------------------------------------------------------------------------------------
#1................. 7 days............... 0 2.3446 000 2.3446 $13,540
#2................. 21 days.............. 0 2.3446 000 2.3446 $13,540
#3................. 35 days.............. 6 2.3446 0.8144 3.1590 $18,243
----------------------------------------------------------------------------------------------------------------
* DRG Weight
** Outlier calculation = 33 percent of per diem weight x number of outlier days = .33 (DRG Weight/Geometric
Mean LOS) x (Patient LOS--Long Stay Threshold)
= .33 (2.3446/5.7) x (35-29)
= .33 (.41133) x 6 (take out to five decimal places)
= .13574 x 6 (take out to five decimal places)
= .8144 (take out to four decimal places)
*** Applied ASA x Total RWP
II. Outpatient Rates 1 2 Per Visit
----------------------------------------------------------------------------------------------------------------
International Interagency
military and other
MEPRS code 4 Clinical service education and Federal agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
A. Medical Care
----------------------------------------------------------------------------------------------------------------
BAA........................... Internal Medicine............... $104.00 $194.00 $204.00
BAB........................... Allergy......................... 53.00 99.00 105.00
BAC........................... Cardiology...................... 87.00 163.00 172.00
BAE........................... Diabetic........................ 61.00 114.00 121.00
BAF........................... Endocrinology (Metabolism)...... 102.00 190.00 201.00
BAG........................... Gastroenterology................ 146.00 272.00 287.00
BAH........................... Hematology...................... 179.00 334.00 352.00
BAI........................... Hypertension.................... 106.00 198.00 208.00
BAJ........................... Nephrology...................... 208.00 387.00 409.00
BAK........................... Neurology....................... 121.00 225.00 238.00
BAL........................... Outpatient Nutrition............ 42.00 79.00 83.00
BAM........................... Oncology........................ 134.00 250.00 264.00
BAN........................... Pulmonary Disease............... 153.00 285.00 301.00
BAO........................... Rheumatology.................... 101.00 188.00 199.00
BAP........................... Dermatology..................... 78.00 146.00 154.00
BAQ........................... Infectious Disease.............. 178.00 332.00 350.00
BAR........................... Physical Medicine............... 83.00 155.00 163.00
BAS........................... Radiation Therapy............... 128.00 238.00 251.00
BAT........................... Bone Marrow Transplant.......... 115.00 214.00 226.00
BAU........................... Genetic......................... 367.00 683.00 721.00
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B. Surgical Care
----------------------------------------------------------------------------------------------------------------
BBA........................... General Surgery................. 148.00 276.00 291.00
BBB........................... Cardiovascular and Thoracic 320.00 595.00 628.00
Surgery.
BBC........................... Neurosurgery.................... 173.00 323.00 341.00
BBD........................... Ophthalmology................... 90.00 168.00 177.00
BBE........................... Organ Transplant................ 399.00 742.00 783.00
BBF........................... Otolaryngology.................. 106.00 197.00 207.00
BBG........................... Plastic Surgery................. 131.00 244.00 258.00
BBH........................... Proctology...................... 84.00 157.00 165.00
[[Page 58865]]
BBI........................... Urology......................... 112.00 209.00 221.00
BBJ........................... Pediatric Surgery............... 167.00 311.00 328.00
BBK........................... Peripheral Vascular............. 78.00 146.00 154.00
............................ Surgery.........................
BBL........................... Pain Management................. 97.00 180.00 190.00
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C. Obstetrical and Gynecological (OB-GYN) Care
----------------------------------------------------------------------------------------------------------------
BCA........................... Family Planning................. 57.00 106.00 112.00
BCB........................... Gynecology...................... 89.00 165.00 175.00
BCC........................... Obstetrics...................... 74.00 138.00 146.00
BCD........................... Breast Cancer Clinic............ 184.00 342.00 361.00
----------------------------------------------------------------------------------------------------------------
D. Pediatric Care
----------------------------------------------------------------------------------------------------------------
BDA........................... Pediatric....................... 62.00 115.00 121.00
BDB........................... Adolescent...................... 65.00 122.00 129.00
BDC........................... Well Baby....................... 42.00 79.00 83.00
----------------------------------------------------------------------------------------------------------------
E. Orthopaedic Care
----------------------------------------------------------------------------------------------------------------
BEA........................... Orthopaedic..................... 93.00 174.00 183.00
BEB........................... Cast............................ 59.00 110.00 117.00
BEC........................... Hand Surgery.................... 69.00 129.00 136.00
BEE........................... Orthotic Laboratory............. 67.00 125.00 132.00
BEF........................... Podiatry........................ 56.00 105.00 111.00
BEZ........................... Chiropractic.................... 25.00 47.00 50.00
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F. Psychiatric and/or Mental Health Care
----------------------------------------------------------------------------------------------------------------
BFA........................... Psychiatry...................... 124.00 230.00 243.00
BFB........................... Psychology...................... 93.00 174.00 184.00
BFC........................... Child Guidance.................. 57.00 105.00 111.00
BFD........................... Mental Health................... 104.00 194.00 204.00
BFE........................... Social Work..................... 102.00 190.00 200.00
BFF........................... Substance Abuse................. 99.00 184.00 195.00
----------------------------------------------------------------------------------------------------------------
G. Family Practice/Primary Medical Care
----------------------------------------------------------------------------------------------------------------
BGA........................... Family Practice................. 74.00 138.00 146.00
BHA........................... Primary Care.................... 77.00 143.00 151.00
BHB........................... Medical Examination............. 80.00 148.00 156.00
BHC........................... Optometry....................... 50.00 93.00 98.00
BHD........................... Audiology....................... 35.00 65.00 69.00
BHE........................... Speech Pathology................ 101.00 188.00 199.00
BHF........................... Community Health................ 66.00 123.00 130.00
BHG........................... Occupational Health............. 73.00 136.00 143.00
BHH........................... TRICARE Outpatient.............. 56.00 104.00 109.00
BHI........................... Immediate Care.................. 107.00 200.00 211.00
----------------------------------------------------------------------------------------------------------------
H. Emergency Medical Care
----------------------------------------------------------------------------------------------------------------
BIA........................... Emergency Medical............... 126.00 234.00 247.00
----------------------------------------------------------------------------------------------------------------
I. Flight Medical Care
----------------------------------------------------------------------------------------------------------------
BJA........................... Flight Medicine................. 88.00 164.00 173.00
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J. Underseas Medical Care
----------------------------------------------------------------------------------------------------------------
BKA........................... Underseas Medicine.............. 43.00 79.00 84.00
----------------------------------------------------------------------------------------------------------------
K. Rehabilitative Services
----------------------------------------------------------------------------------------------------------------
BLA........................... Physical Therapy................ 41.00 77.00 81.00
BLB........................... Occupational Therapy............ 61.00 114.00 120.00
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[[Page 58866]]
III. Ambulatory Procedure Visit (APV) 6 Per Visit
----------------------------------------------------------------------------------------------------------------
International Interagency
military and other
MEPRS code 4 Clinical service education and Federal agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
Medical Care
BB............................ Surgical Care................... 937.00 1,740.00 1,836.00
BD............................ Pediatric Care.................. 233.00 430.00 454.00
BE............................ Orthopaedic Care................ 1,179.00 2,192.00 2,313.00
All other B clinics not included 430.00 797.00 841.00
above (BA, BC, BF, BG, BH, BI,
BJ, BK and BL).
----------------------------------------------------------------------------------------------------------------
IV. Other Rates and Charges 1 2 Per Visit
----------------------------------------------------------------------------------------------------------------
International Interagency
military and other
MEPRS code 4 Clinical service education and Federal agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
FBI........................... A. Immunization................. $16.00 $30.00 $32.00
DGC........................... B. Hyperbaric Chamber 5......... 153.00 285.00 301.00
C. Family Member Rate (formerly 10.85
Military Dependents Rate).
D. Reimbursement Rates For Drugs
Requested By Outside Providers
7
----------------------------------------------------------------------------------------------------------------
The FY 2000 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 based on the DoD-wide average per National
Drug Code (NDC) number. Final rule 32 CFR Part 220, which has still not
been published when this package was prepared, eliminates the high cost
ancillary services' dollar threshold and the associated term ``high
cost ancillary service.'' The phrase ``high cost ancillary service''
will be replaced with the phrase ``ancillary services requested by an
outside provider'' on publication of final rule 32 CFR Part 220. The
list of drug reimbursement rates is too large to include here. These
rates are available on request from OASD (Health Affairs)--see Tab O
for the point of contact.
E. Reimbursement Rates for Ancillary Services Requested By Outside
Providers 8
Final rule 32 CFR Part 220, which has still not been published when
this package was prepared, eliminates the high cost ancillary services'
dollar threshold and the associated term ``high cost ancillary
service.'' The phrase ``high cost ancillary service'' will be replaced
with the phrase ``ancillary services requested by an outside provider''
on publication of final rule 32 CFR Part 220. The list of FY 2000 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 O for the
point of contact.
F. Elective Cosmetic Surgery Procedures and Rates
----------------------------------------------------------------------------------------------------------------
International
Cosmetic surgery procedure Classification Current Procedural FY 2000 charge 10 Amount of
Diseases (ICD-9) Terminology (CPT) charge
--------------------------------------------------------------9-------------------------------------------------
Mammaplasty--augmentation...... 85.50, 85.32, 19325, 19324, Inpatient Surgical (a) (b)
85.31. 19318. Care Per Diem Or APV.
Mastopexy...................... 85.60............. 19316............. Inpatient Surgical (a b c)
Care Per Diem Or APV
or applicable
Outpatient Clinic
Rate.
Facial......................... 86.82............. 15824............. Inpatient Surgical (a b)
Care Per Diem Or APV.
Rhytidectomy................... 86.22............. ................ ....................
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.................... 76.68............. 21208............. Inpatient............. (a)
(Augmentation/Reduction)....... 76.67............. 21209............. Surgical Care Per Diem (b c)
Or APV or applicable
Outpatient Clinic
Rate.
Abdominoplasty................. 86.83............. ................ Inpatient Surgical (a)
Care Per Diem.
Lipectomy Suction per region 11 86.83............. 15876, 15877, Inpatient Surgical (a b c)
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............. .................. Inpatient Surgical (a)
Repositioning. Care Per Diem.
Dermabrasion................... .................. 15780............. APV or applicable (b c)
Outpatient Clinic
Rate.
Hair Restoration............... .................. 15775............. APV or applicable (b c)
Outpatient Clinic
Rate.
Removing Tattoos............... .................. 15780............. APV or applicable (b c)
Outpatient Clinic
Rate.
Chemical Peel.................. .................. 15790............. APV or applicable (b c)
Outpatient Clinic
Rate.
Arm/Thigh Dermolipectomy....... 86.83............. 15836/15832....... Inpatient Surgical (a b)
Care Per Diem Or APV.
[[Page 58867]]
Refractive surgery............. .................. .................. APV or applicable (b c)
Outpatient Clinic
Rate.
Radial Keratotomy.............. .................. 65771
Other Procedure (if applies to .................. 66999
laser or other refractive
surgery).
Otoplasty...................... .................. 69300............. APV or applicable (a b c)
Outpatient Clinic
Rate.
Brow Lift...................... 86.3.............. 15839............. Inpatient Surgical (a b)
Care Per Diem Or APV.
----------------------------------------------------------------------------------------------------------------
G. Dental Rate \12\ Per Procedure
----------------------------------------------------------------------------------------------------------------
International Interagency &
military other Federal
MEPRS code \4\ Clinical service education and agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
Dental Services .............................. $45.00 $109.00 $115.00
ADA code and DoD established
weight..
----------------------------------------------------------------------------------------------------------------
H. Ambulance Rate 13 Per Visit
----------------------------------------------------------------------------------------------------------------
International Interagency &
military other Federal
MEPRS code \4\ Clinical service education and agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
FEA........................... Ambulance....................... $62.00 $116.00 $122.00
----------------------------------------------------------------------------------------------------------------
I. Ancillary Services Requested by an Outside Provider \8\ Per
Procedure
----------------------------------------------------------------------------------------------------------------
International Interagency &
military other Federal
MEPRS code \4\ Clinical service education and agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
Laboratory procedures requested $13.00 $20.00 $21.00
by an outside provider CPT '99
Weight Multiplier.
Radiology procedures requested $57.00 $86.00 $90.00
by an outside provider CPT '99
Weight Multiplier.
----------------------------------------------------------------------------------------------------------------
J. AirEvac Rate \14\ Per Visit
----------------------------------------------------------------------------------------------------------------
International Interagency &
military other Federal
MEPRS code \4\ Clinical service education and agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
AirEvac Services--Ambulatory.... $195.00 $364.00 $384.00
AirEvac Services--Litter........ $567.00 $1,056.00 $1,114.00
----------------------------------------------------------------------------------------------------------------
K. Observation Rate \15\ Per hour
----------------------------------------------------------------------------------------------------------------
International Interagency &
military other Federal
MEPRS code \4\ Clinical service education and agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
Observation Services--Hour...... $17.00 $31.00 $32.00
----------------------------------------------------------------------------------------------------------------
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
ambulatory procedure visit (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
Sections 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 98 percent hospital and 2 percent
professional charges. The outpatient per visit percentages are 89
percent outpatient services and 11 percent professional charges.
[[Page 58868]]
\2\ DoD civilian employees located in overseas areas shall be
rendered a bill when services are performed.
\3\ The cost per Diagnosis Related Group (DRG) 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
sub account 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:
MEPRS CODE
Outpatient Care (Functional Category)--B
Medical Care (Summary Account)--BA
Internal Medicine (Subaccount)--BAA
\5\ Hyperbaric service 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 is defined in DOD Instruction
6025.8, ``Ambulatory Procedure Visit (APV),'' dated 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 unit (APU). An APU is a location
or organization within an MTF (or freestanding outpatient clinic)
that is specially equipped, staffed and designated for the purpose
of providing the intensive level of care associated with APVs. Care
is required in the facility for less than 24 hours. All expenses and
workload are assigned to the MTF-established APU associated with the
referring clinic. The BB, BD and BE APV rates are only to be used by
clinics that are subaccounts under these summary accounts (see (\4\)
for an explanation of MEPRS hierarchical arrangement). The All Other
APV rate is to be used only by those clinics that are not a
subaccount under BB, BD or BE.
\7\ Prescription services requested by outside providers (e.g.,
physicians or dentists) that 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
only come to the MTF for prescription services. The standard cost of
medications ordered by an outside provider that includes the cost of
the drugs plus a dispensing fee per prescription. The prescription
cost is calculated by multiplying the number of units (e.g., tablets
or capsules) by the unit cost and adding a $6.00 dispensing fee per
prescription. Final rule 32 CFR Part 220, which has still not been
published when this package was prepared, eliminates the high cost
ancillary services' dollar threshold and the associated term ``high
cost ancillary service.'' The phrase ``high cost ancillary service''
will be replaced with the phrase ``ancillary services requested by
an outside provider'' on publication of final rule 32 CFR Part 220.
The elimination of the threshold also eliminates the need to bundle
costs whereby a patient is billed if the total cost of ancillary
services in a day (defined as 0001 hours to 2400 hours) exceeded
$25.00. The elimination of the threshold is effective as per date
stated in final rule 32 CFR Part 220.
\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 which are
prescribed by providers external to the MTF. Laboratory and
Radiology procedure costs are calculated by multiplying the DoD
established weight for the Physicians' Current Procedural
Terminology (CPT '99) code 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
only come to the MTF for ancillary services.
Final rule 32 CFR Part 220, which has still not been published
when this package was prepared, eliminates the high cost ancillary
services' dollar threshold and the associated term ``high cost
ancillary service.'' The phrase ``high cost ancillary service'' will
be replaced with the phrase ``ancillary services requested by an
outside provider'' on publication of final rule 32 CFR Part 220. The
elimination of the threshold also eliminates the need to bundle
costs whereby a patient is billed if the total cost of ancillary
services in a day (defined as 0001 hours to 2400 hours) exceeded
$25.00. The elimination of the threshold is effective as per date
stated in final rule 32 CFR Part 220.
\9\ The attending physician is to complete the CPT '99 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 FY 2000 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 Sections 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\ 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.
\13\ 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).
\14\ Air in-flight medical care reimbursement charges are
determined by the status of the patient (ambulatory or litter) and
are per patient. The appropriate charges are billed only by the Air
Force Global Patient Movement Requirement Center (GPMRC). These
charges are only for the cost of providing medical care. Flight
charges are billed by GPMRC separately using the commercial rate
effective the date of travel plus $1.
[[Page 58869]]
\15\ Observation Services are billed at the hourly charge. Begin
counting when the patient is placed in the observation bed and round
up to the nearest hour. If a patient status changes to inpatient,
the charges for observation services are added to the DRG assigned
to the case and not billed separately. If a patient is released from
Observation status and is sent to an APV, the charges for
Observation services are not billed separately but are added to the
APV rate to recover all expenses.
2. Department of Health and Human Services
For the Department of Health and Human Services, Indian Health
Service, effective October 1, 1999 and thereafter:
Hospital Care Inpatient Day
General Medical Care............... Alaska.................... $1,925
Rest of the United States. 1,313
Outpatient Medical Treatment
Outpatient Visit................... Alaska.................... 308
Rest of the United States. 211
3. Department of Veterans Affairs
Effective October 1, 1999, and thereafter:
------------------------------------------------------------------------
Tortiously Interagency
liable rates rates
------------------------------------------------------------------------
Hospital Care, Rates Per Inpatient Day
------------------------------------------------------------------------
General Medicine:
Total............................... $1610 $1476
Physician....................... 193
Ancillary....................... 420
Nursing, Room, and Board........ 997
Neurology:
Total............................... 1927 1757
Physician....................... 282
Ancillary....................... 509
Nursing, Room, and Board........ 1136
Rehabilitation Medicine:
Total............................... 1065 974
Physician....................... 121
Ancillary....................... 325
Nursing, Room, and Board........ 619
Blind Rehabilitation:
Total............................... 1009 928
Physician....................... 81
Ancillary....................... 501
Nursing, Room, and Board........ 427
Spinal Cord Injury:
Total............................... 970 885
Physician....................... 120
Ancillary....................... 244
Nursing, Room, and Board........ 606
Surgery:
Total............................... 3023 2788
Physician....................... 333
Ancillary....................... 917
Nursing, Room, and Board........ 1773
General Psychiatry:
Total............................... 640 577
Physician....................... 60
Ancillary....................... 101
Nursing, Room, and Board........ 479
Substance Abuse (Alcohol and Drug
Treatment):
Total............................... 339 308
Physician....................... 32
Ancillary....................... 78
Nursing, Room, and Board........ 229
Intermediate Medicine:
Total............................... 491 446
Physician....................... 24
Ancillary....................... 72
Nursing, Room, and Board........ 395
------------------------------------------------------------------------
Nursing Home Care, Rates Per Day
------------------------------------------------------------------------
Nursing Home Care:
Total............................... 339 307
Physician....................... 11
Ancillary....................... 46
Nursing, Room, and Board........ 282
------------------------------------------------------------------------
[[Page 58870]]
Outpatient Medical and Dental Treatment
------------------------------------------------------------------------
Outpatient Visit (other than Emergency 254 236
Dental)................................
Emergency Dental Outpatient Visit....... 157 140
Prescription Filled..................... 36 35
------------------------------------------------------------------------
For the period beginning October 1, 1999, the rates prescribed
herein superseded those established by the Director of the Office of
Management and Budget October 16, 1998 (61 FR 56360).
Jacob J. Lew,
Director, Office of Management and Budget.
[FR Doc. 99-28115 Filed 10-29-99; 8:45 am]
BILLING CODE 3110-01-P
