[Federal Register Volume 63, Number 212 (Tuesday, November 3, 1998)]
[Notices]
[Pages 59290-59291]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-29315]
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DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE/CHAMPUS; FY99 DRG Updates
AGENCY: Office of the Secretary, DOD.
ACTION: Notice of DRG revised rates.
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SUMMARY: This notice describes the changes made to the TRICARE/CHAMPUS
DRG-based payment system in order to conform to changes made to the
Medicare Prospective Payment System (PPS). It also provides the updated
fixed loss cost outlier threshold, cost-to-charge ratios and the
Internet address for accessing the updated adjusted standardized
amounts, DRG relative weights, and beneficiary cost-share per diem
rates to be used for FY 1999 under the TRICARE/CHAMPUS DRG-based
payment system.
EFFECTIVE DATES: The rates, weights and Medicare PPS changes which
affect the TRICARE/CHAMPUS DRG-based payment system contained in this
notice are effective for admissions occurring on or after October 1,
1998.
ADDRESSES: TRICARE Management Activity (TMA), Medical Benefits and
Reimbursement Systems, 16401 East Centretech Parkway, Aurora, CO 80011-
9403.
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, Medical Benefits and Reimbursement Systems, TMA, telephone
(303) 676-3627. To obtain copies of this document, see the ADDRESSES
section above. Questions regarding payment of specific claims under the
TRICARE/CHAMPUS DRG-based payment system should be addressed to the
appropriate 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), October 22, 1990 (55 FR 42560), and September 10, 1998 (63 FR
48439).
An explicit tenet of these final rules, and one based on the
statute authorizing the use of DRGs by TRICARE/CHAMPUS, is that the
TRICARE/CHAMPUS DRG-based payment system is modeled on the Medicare
PPS, and that, whenever practicable, the TRICARE/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.
[[Page 59291]]
I. Medicare PPS Changes Which Affect the TRICARE/CHAMPUS DRG-Based
Payment System
Following is a discussion of the changes the Health Care Financing
Administration (HCFA) has made to the Medicare PPS that affect the
TRICARE/CHAMPUS DRG-based payment system.
A. DRG Classifications
Under both the Medicare PPS and the TRICARE/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
TRICARE/CHAMPUS DRG-based payment system is the same as the current
Medicare Grouper with two modifications. The TRICARE/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 was changed so the age split
(age <29 days)="" and="" assignments="" to="" mdc="" 15="" occur="" before="" assignment="" of="" the="" premdc="" drgs.="" this="" resulted="" in="" all="" neonate="" tracheostomies="" and="" organ="" transplants="" to="" be="" grouped="" to="" mdc="" 15="" drgs="" and="" not="" to="" drgs="" 480-483="" or="" 495.="" for="" admissions="" occurring="" on="" or="" after="" october="" 1,="" 1998,="" the="" champus="" grouper="" hierarchy="" logic="" was="" changed="" to="" move="" drg="" 103="" to="" the="" premdc="" drgs="" and="" to="" assign="" patients="" to="" premdc="" drgs="" 480,="" 103="" and="" 495="" before="" assignment="" to="" mdc="" 15="" drgs="" and="" the="" neonatal="" drgs.="" grouping="" for="" all="" other="" drgs="" under="" the="" tricare/champus="" system="" is="" identical="" to="" the="" medicare="" pps.="" for="" fy="" 1999,="" 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="" tricare/champus="" will="" continue="" to="" use="" the="" same="" wage="" index="" amounts="" used="" for="" the="" medicare="" pps.="" in="" addition,="" tricare/champus="" will="" duplicate="" all="" changes="" with="" regard="" to="" the="" wage="" index="" for="" specific="" hospitals="" that="" are="" redesignated="" by="" the="" medicare="" geographic="" classification="" review="" board.="" c.="" hospital="" market="" basket="" tricare/champus="" will="" update="" the="" adjusted="" standardized="" amounts="" according="" to="" the="" final="" updated="" hospital="" market="" basket="" used="" for="" the="" medicare="" pps="" according="" to="" hcfa's="" july="" 31,="" 1998,="" final="" rule.="" d.="" outlier="" payments="" since="" tricare/champus="" does="" not="" include="" capital="" payments="" in="" our="" drg-="" based="" payments,="" we="" will="" use="" the="" fixed="" loss="" cost="" outlier="" threshold="" calculated="" by="" hcfa="" for="" paying="" cost="" outliers="" in="" the="" absence="" of="" capital="" prospective="" payments.="" for="" fy99,="" the="" fixed="" loss="" cost="" outlier="" threshold="" is="" based="" on="" the="" sum="" of="" the="" applicable="" drg-based="" payment="" rate="" plus="" any="" amounts="" payable="" for="" idme="" plus="" a="" fixed="" dollar="" amount.="" thus,="" for="" fy99,="" in="" order="" for="" a="" case="" to="" qualify="" for="" cost="" outlier="" payments,="" the="" costs="" must="" exceed="" the="" tricare/champus="" drg="" base="" payment="" rate="" for="" the="" drg="" plus="" the="" idme="" payment="" plus="" $10,129="" (wage="" adjusted).="" the="" marginal="" cost="" factor="" for="" cost="" outliers="" continues="" to="" be="" 80="" percent.="" e.="" graduate="" medical="" education="" tricare/champus="" will="" adopt="" medicare's="" pps="" changes="" as="" they="" pertain="" to="" the="" counting="" and="" reporting="" of="" residents="" on="" the="" medicare="" cost="" reports="" for="" purposes="" of="" reimbursing="" hospitals="" for="" the="" tricare/champus="" share="" of="" graduate="" medical="" education="" costs.="" f.="" transfers="" tricare/champus="" will="" adopt="" medicare's="" pps="" changes="" as="" they="" pertain="" to="" the="" expanded="" transfer="" definition.="" we="" will="" publish="" an="" interim="" final="" rule="" to="" reflect="" these="" changes="" in="" 32="" cfr="" part="" 199(a)(1).="" g.="" blood="" clotting="" factor="" tricare/champus="" will="" adopt="" the="" two="" new="" hcpcs="" billing="" codes="" and="" payment="" rates="" for="" purified="" factor="" ix="" products,="" as="" outlined="" in="" hcfa's="" may="" 12,="" 1998,="" final="" rule.="" these="" new="" codes="" and="" payment="" rates="" are="" effective="" for="" admissions="" on="" or="" after="" june="" 11,="" 1998.="" in="" addition,="" we="" will="" adopt="" the="" changes="" to="" the="" payment="" rates="" for="" blood="" clotting="" factor="" for="" hemophilia="" patients="" as="" outlined="" in="" hcfa's="" july="" 31,="" 1998,="" final="" rule,="" effective="" for="" admissions="" on="" or="" after="" october="" 1,="" 1998.="" h.="" bad="" debt="" increase="" tricare/champus="" will="" adopt="" medicare's="" pps="" changes="" to="" gradually="" reduce="" the="" payment="" for="" bad="" debt="" for="" hospitals="" over="" the="" next="" several="" years.="" ii.="" cost="" to="" charge="" ratio="" for="" fy="" 1999,="" the="" cost-to-charge="" ratio="" used="" for="" the="" tricare/champus="" drg-based="" payment="" system="" will="" be="" 0.5487,="" which="" is="" increased="" to="" 0.5562="" 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="" 0.6085.="" iii.="" updated="" rates="" and="" weights="" the="" updated="" rates="" and="" weights="" are="" accessible="" through="" the="" internet="" at="">http://www.tso.osd.mil under the heading Provider Reimbursement
Rates. Table 1 provides the ASA rates and Table 2 provides the DRG
weights to be used under the TRICARE/CHAMPUS DRG-based payment system
during FY 1999 and which is a result of the changes described above.
The implementing regulations for the TRICARE/CHAMPUS DRG-based payment
system are in 32 CFR Part 199.
Dated: October 27, 1998.
L.M. Bynum,
Alternate Federal Register Liaison Officer, Department of Defense.
[FR Doc. 98-29315 Filed 11-2-98; 8:45 am]
BILLING CODE 5000-04-M
