[Federal Register Volume 59, Number 70 (Tuesday, April 12, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-8728]
[[Page Unknown]]
[Federal Register: April 12, 1994]
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DEPARTMENT OF DEFENSE
Office of the Secretary
Medical and Dental Reimbursements Rates for Period April 1, 1994
through September 30, 1994 (Fiscal Year 1994)
Notice is hereby given that the Deputy Chief Financial Officer of
the Department of Defense, in a memorandum of March 10, 1994,
established the following reimbursement rates for inpatient and
outpatient medical and dental care to be provided during the period of
April 1, 1994 through September 30, 1994.
Inpatient, Outpatient and Other Rates and Charges
I.--Inpatient and Outpatient Rates
[Notes to appear at end of document]
------------------------------------------------------------------------
International Interagency
military other federal
Per inpatient day education and agency Other
training sponsored
(IMET) patients
------------------------------------------------------------------------
A. Burn center.......... $1,735 $2,795 $2,975
B. Inpatient other than
burn center\1\......... .............. .............. ..............
Medical care services... 329 737 783
Surgical care services.. 457 1,025 1,082
Obstetrical and
gynecological care..... 430 965 1,020
Pediatric care.......... 330 740 785
Orthopedic care......... 412 924 977
Psychiatric care and
substance abuse........ 198 444 479
Medical intensive care
and coronary care...... 724 1,623 1,703
Surgical intensive care. 789 1,769 1,855
Neonatal intensive care. 459 1,029 1,087
Organ and bone marrow
transplant............. 651 1,460 1,533
Same day surgery........ 179 401 426
(See section II, item H, which outlines the types of services/care
provided within each inpatient area.)
II. Per Outpatient
Visit:
A. Medical treatment
facilities......... $47 \2\$95 $101
B. PRIMUS/NAVCARE... N/A N/A \3\61
III. Other Rates and
Charges:...............
A. Hyperbaric
Services:..........
1-60 minutes.... $83 $167 $177
61-120 minutes.. 161 325 345
121-180 minutes. 239 482 512
181-240 minutes. 317 639 679
(Note: Charges may be
prorated based on
usage)
B. Military
Dependents......... .............. 9.30 ..............
C. Per FAA Air
Traffic Controller
Examination........ N/A 96 N/A
------------------------------------------------------------------------
D. High Cost Medications Requested by External Providers\3\
[Notes to appear at end of document]
----------------------------------------------------------------------------------------------------------------
Total dispensed Standard
Generic (trade) name Strength quantity\4\ cost
----------------------------------------------------------------------------------------------------------------
Acyclovir (Zovirax).................................... 800mg............... 100................. $286
Acyclovir oint......................................... 15g................. 6 Tubes............. 161
Aminoglutethamide (Cytadren)........................... 250mg............... 360................. 376
Amiodarone (Cardarone)................................. 200mg............... 180................. 218
Amlodipine (Norvasc)................................... 2.5mg............... 270................. 248
Amlodipine (Norvasc)................................... 5mg................. 270................. 252
Astemizole (Hismanal).................................. 50mg................ 90.................. 109
Auranofin (Ridaura).................................... 3mg................. 180................. 153
Betoxolol (Betoptic)................................... .25%................ 3 bottles........... 114
Bromocriptine.......................................... 2.5mg............... 270................. 454
Buspirone (Buspar)..................................... 5mg................. 270................. 121
Buspirone (Buspar)..................................... 10mg................ 270................. 208
Calcitonin (Calcimar).................................. 200 IU.............. 8 vials............. 179
Captopril (Capoten).................................... 25mg................ 270................. 134
Captopril (Capoten).................................... 50mg................ 270................. 221
Captopril (Capoten).................................... 100mg............... 270................. 333
Carbenicillin.......................................... 382mg............... 40.................. 103
Caridopa/Levodopa CR (Sinemet CR)...................... .................... 270................. 291
Caridopa/Levodopa (Sinemet 25/100)..................... 25/100.............. 360................. 184
Caridopa/Levodopa (Sinemet 25/250)..................... 25/250.............. 360................. 235
Chemstrip BG II........................................ .................... 360................. 271
Cholestyramine powder.................................. .................... 6 cans.............. 151
Cholestyramine powder light............................ .................... 6 cans.............. 129
Cimetidine............................................. 400mg............... 180................. 146
Cimetidine............................................. 300mg............... 360................. 164
Cimetidine syrup....................................... .................... 3 bottles........... 150
Clemastine (Tavist).................................... 2.68mg.............. 270................. 183
Clomipramine (Anafranil)............................... 50mg................ 360................. 292
Clomipramine (Anafranil)............................... 25mg................ 360................. 210
Colestipol............................................. 5mg packets......... 360 pkt............. 274
Cromolyn inhaler....................................... .................... 4 bottles........... 183
Cromolyn soln (nebulizer).............................. .................... 360 amp............. 204
Cyclophosphamide....................................... 25mg................ 360................. 360
Cyclophosphamide....................................... 50mg................ 360................. 681
Cyclosporine........................................... 100mg............... 60.................. 257
Cyclosporine........................................... 100mg/ml sol........ 3 bottles........... 639
Danazol (Danocrine).................................... 200mg............... 180................. 320
Demeclocycline......................................... 150mg............... 60.................. 145
Desmopressin nasal soln (DDAVP)........................ .................... 20 ml............... 367
Desmopressin nasal spray............................... .................... 20 ml............... 328
Diclofenac (Voltaren).................................. 75mg................ 180................. 150
Diclofenac (Voltaren).................................. 50mg................ 270................. 187
Didanosine............................................. 150mg............... 180................. 357
Didanosine (Videx)..................................... 25mg................ 360................. 124
Didanosine (Videx)..................................... 100mg............... 360................. 475
Diflucan............................................... 100mg............... 30.................. 182
Diflucan............................................... 200mg............... 30.................. 298
Diflunisal (Dolobid)................................... 500mg............... 180................. 173
Diltiazem 60mg (Cardizem).............................. 60mg................ 270................. 130
Diltiazem CD (Cardizem CD)............................. 240mg............... 90.................. 135
Diltiazem CD (Cardizem CD)............................. 300mg............... 90.................. 174
Diltiazem SR........................................... 120mg............... 180................. 144
Diltiazem SR........................................... 60mg................ 180................. 111
Diltiazem (Cardizem)................................... 120mg............... 360................. 315
Divalproax (Depakote).................................. 250mg............... 360................. 146
Elase ointment......................................... .................... 6 tubes............. 157
Enalapril.............................................. 5mg................. 180................. 127
Enalapril.............................................. 20mg................ 180................. 190
Enalapril.............................................. 10mg................ 180................. 134
Epoetin Alfa 2000...................................... .................... 24.................. 478
Epoetin Alfa 3000...................................... .................... 24.................. 727
Epoetin Alfa 4000...................................... .................... 24.................. 979
Estramustine (Emcyt)................................... 150mg............... 150................. 361
Ethambutol............................................. 400mg............... 180................. 177
Ethosuximide........................................... 250mg............... 360................. 167
Etidronate Disodium.................................... 400mg............... 90.................. 164
Etidronate Disodium (Didronel)......................... 200mg............... 270................. 492
Etoposide (VePesid).................................... 50mg................ 25.................. 619
Exactech............................................... .................... 90 days............. 450
Famotidine (Pepcid).................................... 20mg................ 180................. 152
Fentanyl patch......................................... 100mcg.............. 10.................. 245
Fentanyl patch......................................... 75mcg............... 10.................. 203
Fluconazole (Diflucan)................................. 200mg............... 30.................. 298
Fluconazole (Diflucan)................................. 100mg............... 30.................. 182
Fluconazole (Diflucan)................................. 50mg................ 30.................. 116
Fluoxetine (Prozac).................................... 20mg................ 60.................. 102
Flurbiprofen (Ansaid).................................. 100mg............... 90.................. 150
Flutamide (Eulexin).................................... 125mg............... 540................. 597
Gemfibrozil (Lopid).................................... 600mg............... 180................. 160
Glipizide.............................................. 10mg................ 180................. 177
Hemofil M.............................................. .................... 30 days............. 6,816
Hydroxychloroquine..................................... 200mg............... 180................. 178
Hydroxyurea (Hydrea)................................... 500mg............... 270................. 308
Interferon (Intron A).................................. 3mu................. 12.................. 287
Isotretinoin (Accutane)................................ 10mg................ 60.................. 133
Isotretinoin (Accutane)................................ 20mg................ 60.................. 158
Isotretinoin (Accutane)................................ 40mg................ 60.................. 182
Itraconazole (Sporonox)................................ 10mg................ 30.................. 127
Leucovorin............................................. 5mg................. 100................. 166
Leuprolide (Lupron).................................... 7.5mg............... 1................... 387
Leuprolide (Lupron).................................... 3.75mg.............. 1................... 278
Lisinopril............................................. 10mg................ 180................. 112
Lisinopril (Prinivil).................................. 5mg................. 180................. 112
Lomustine.............................................. 40mg................ 20.................. 182
Lomustine.............................................. 100mg............... 20.................. 400
Lovastatin (Mevacor)................................... 20mg................ 180................. 265
Lovastatin (Mevacor)................................... 40mg................ 180................. 492
Loxapine (Loxitane).................................... 50mg................ 180................. 138
Lypressin spray (Diapid)............................... .................... 4 bottles........... 116
Megestrol (Megace)..................................... 20mg................ 360................. 120
Megestrol (Megace)..................................... 40mg................ 360................. 228
Melphalan (Alkeran).................................... 2mg................. 350................. 410
Mesalamine enema (Rowasa).............................. 500mg............... 90.................. 158
Metaproterenol neb soln................................ 0.6%................ 100................. 105
Methazolamide.......................................... 50mg................ 270................. 166
Methotrexate........................................... 2.5mg............... 180................. 170
Methysergide Maleate................................... 2mg................. 180................. 182
Mexiletine (Mexitil)................................... 200mg............... 270................. 156
Mexiletine (Mexitil)................................... 250mg............... 270................. 185
Mexiletine (Mexitil)................................... 150mg............... 270................. 131
Misoprostol............................................ 200mcg.............. 360................. 197
Naproxen............................................... 500mg............... 180................. 176
Naproxen............................................... 375mg............... 270................. 216
Naproxen............................................... 250mg............... 270................. 168
Nicotine Transdermal System............................ 21mg................ 30.................. 100
Nifedipine............................................. 60mg XL............. 90.................. 151
Nifedipine............................................. 90mg XL............. 90.................. 181
Nortriptyline HCL...................................... 25mg................ 90.................. 107
Olsalazine (Dipentim).................................. 250mg............... 360................. 149
Omperazole (Prilosec).................................. 20mg................ 90.................. 268
One Touch Test Strips.................................. .................... 360................. 171
Pancrelipase MT16...................................... .................... 540................. 313
Pancrelipase (Pancrease)............................... .................... 540................. 119
Penicillamine.......................................... 250mg............... 360................. 260
Perphenazine........................................... 2mg................. 360................. 111
Pravastin Sodium (Pravachol)........................... 10mg................ 90.................. 125
Pravastin Sodium (Pravachol)........................... 20mg................ 90.................. 132
Probucol (Lorelco)..................................... 250mg............... 360................. 184
Procarbazine (Matulane)................................ 50mg................ 360................. 204
Procyclidine (Kemadrin)................................ 5mg................. 360................. 113
Pyrazinamide........................................... 500mg............... 360................. 430
Ranitidine............................................. 150mg............... 180................. 152
Rifampin with INH...................................... .................... 180................. 493
Selegeline (Eldepryl).................................. 5mg................. 180................. 416
Somatrem (Protropin)................................... 5mg................. 4................... 770
Somatropin (Humatrope)................................. .................... 6 Vials............. 1,126
Sucalfate (Carafate)................................... 1GM................. 360................. 183
Sulindac............................................... 150mg............... 360................. 112
Sulindac............................................... 200mg............... 360................. 139
Tamoxifen (Nolvadex)................................... 10mg................ 180................. 207
Terfenadine (Seldane).................................. .................... 180................. 124
Ticlopidine (Ticlid)................................... 250mg............... 180................. 219
Tocainide (Tonocard)................................... 400mg............... 270................. 181
Tocainide (Tonocard)................................... 600mg............... 270................. 231
Tracer BG Strips....................................... .................... 360................. 252
Ursidiol (Actigall).................................... 300mg............... 90.................. 145
Verapamil SR 240 (Calan SR)............................ .................... 180................. 100
Zalcitabine (Hivid).................................... .75mg............... 270................. 542
Zidovudine (Retrovir).................................. 100mg............... 450................. 598
----------------------------------------------------------------------------------------------------------------
E. High Cost Services Requested by External Providers\3\
[Notes to appear at end of document]
------------------------------------------------------------------------
Service provided Cost of service
------------------------------------------------------------------------
X-Ray Ribs (all), per side........................... $114
X-Ray Hips, Bilateral................................ 116
Upper Gastrointestinal (G.I.) study with contrast.... 146
Hysterosalpingogram.................................. 128
Mammogram, Bilateral or with localization............ 131
Ultrasound, per study................................ 117
Ultrasound--complete abdomen or with biopsy.......... 203
Computerized Axial Tomography (CAT) scan head/brain
without contrast.................................... 198
Computerized Axial Tomography (CAT) scan head/brain
with contrast....................................... 223
Computerized Axial Tomography (CAT) scan head/brain
with and without contrast, or post fossa and IAM/
IACS................................................ 315
Computerized Axial Tomography (CAT) scan chest....... 348
Computerized Axial Tomography (CAT) scan abdomen, per
study............................................... 172
Computerized Axial Tomography (CAT) scan extremity
without contrast.................................... 201
Computerized Axial Tomography (CAT) scan extremity
with contrast....................................... 232
Computerized Axial Tomography (CAT) scan extremity
with and without contrast........................... 306
Magnetic Resonance Imaging (MRI) without contrast.... 287
Magnetic Resonance Imaging (MRI) with contrast brain. 495
Magnetic Resonance Imaging (MRI) spine (all) chest
and abdomen without contrast........................ 235
Magnetic Resonance Imaging (MRI) spine (all) with
contrast............................................ 523
Magnetic Resonance Imaging (MRI) extremities without
contrast............................................ 370
Magnetic Resonance Imaging (MRI) extremities with and
without contrast.................................... 287
------------------------------------------------------------------------
F. Elective Cosmetic Surgery Procedures and Rates
[Notes to appear at end of document]
--------------------------------------------------------------------------------------------------------------------------------------------------------
International Common
classification procedure Full
Cosmetic surgery procedure diseases (ICD- terminology Fiscal year 1994 charge\6\ reimbursement
9) (CPT)\5\
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mammaplasty.......................................... 85.50 19325 Surgical care services............................ $1,082
85.32 19324 or................................................
85.31 19318 Same day surgery.................................. 426
Mastopexy............................................ 85.60 19316 Surgical care services............................ 1,082
or................................................
Same day surgery.................................. 426
Facial rhytidectomy.................................. 86.82 15824 Surgical care services............................ 1,082
86.22 or................................................
Same day surgery.................................. 426
Blepharoplasty....................................... 08.70 15820 Surgical care services............................ 1,082
08.44 15821 or................................................
15822 Same day surgery.................................. 426
15823 ..................................................
Mentoplasty (augumentation reduction)................ 76.68 21208 Surgical care services............................ 1,082
76.67 21209 or................................................
Same day surgery.................................. 426
Abdominoplasty....................................... 86.83 15831 Surgical care services............................ 1,082
or................................................
Same day surgery.................................. 426
Lipectomy, suction per region\7\..................... 86.83 15876 Surgical care services............................ 1,082
15877 or................................................
15878 Same day surgery.................................. 426
15879 ..................................................
Rhinoplasty.......................................... 21.87 30400 Surgical care services............................ 1,082
21.86 30410 or................................................
same day surgery.................................. 426
Scar revisions beyong CHAMPUS........................ 86.84 1578 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Mandibular or maxillary repositioning................ 76.41 21194 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Minor skin lesions\8\................................ 86.30 1578 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Dermabrasion......................................... 86.25 15780 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Hair restoration..................................... 86.64 15775 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Removing tatoos...................................... 86.25 15780 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Chemical peel........................................ 86.24 15790 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Arm/thigh dermolipectomy............................. 86.83 1583-- Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
Brow lift............................................ 86.3 15839 Surgical care services............................ 1082
or................................................
Same day surgery.................................. 426
--------------------------------------------------------------------------------------------------------------------------------------------------------
G. Immunizations--$18
H. Clinical Services By Type of Service/Care Provided
------------------------------------------------------------------------
Inpatient rate Items included
------------------------------------------------------------------------
Medical Care Services.. Internal Medicine, Cardiology, Dermathology,
Endocrinology, Gastroenterology, Hematology,
Nephrology, Neurology, Oncology, Pulmonary and
Upper Respiratory Disease, Rheumatology,
Physical Medicine, Clinical Immunology, HIV-
III Acquired Immune Deficiency Syndrome
(AIDS), Infectious Disease, Allergy, and
Medical Care not elsewhere classified.
Includes Family Practice Medical Care.
Surgical Care Services. General Surgery, Cardiovascular and Thoracic
Surgery, Neurosurgery, Ophthalmology, Oral
Surgery, Otorhinolaryngology, Pediatric
Surgery, Plastic Surgery, Proctology, Urology,
Peripheral Vascular Surgery, Trauma Center,
Head and Neck Surgery, and Surgical Care not
elsewhere classified. Includes Family Practice
Surgical Care.
Obstetrical and Includes Family Practice, Obstetrics and
Gynecological Care. Gynecology.
Pediatric Care......... Pediatrics, Nursery, Adolescent Pediatrics and
Pediatric Care not elsewhere classified.
Includes Family Practice Pediatric and Nursery
Care.
Orthopedic Care........ Orthopedics, Podiatry and Hand Surgery.
Includes Family Practice Orthopedic Care.
Psychiatric Care and Includes Family Practice Psychiatric Care.
Substance Abuse
Rehabilitation.
Medical Intensive Care/ Self-Explanatory.
Coronary Care.
Surgical Intensive Care Self-Explanatory.
Neonatal Intensive..... Self-Explanatory.
Organ and Bone Marrow Self-Explanatory.
Transplants.
Same Day Surgery....... Self-Explanatory.
------------------------------------------------------------------------
Notes on Reimbursable Rates
\1\Daily percentages are applied to both inpatient and
outpatient services provided when billing third party payers (such
as insurance companies). Pursuant to the provisions of 10 U.S.C.
1095, the inpatient daily percentages are 55 percent hospital, 5
percent physician, 40 percent ancillary. The outpatient daily
percentages are 57 percent hospital, 10 percent physicians and 33
percent ancillary.
\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\Charges for PRIMUS/NAVCARE and high cost medications/services
requested by external providers (Physicians, Dentists, etc.) are
only relevant to the Third Party Collection Program. Third party
payers (such as insurance companies) shall be billed for high cost
services in those instances in which non-active duty eligible
beneficiaries have medical insurance and are seen by providers
external to a Military Medical Treatment Facility (MTF) and obtain
the prescribed service or medication from an MTF. Eligible
beneficiaries are not personally liable for this cost and shall not
be billed by the MTF. The standard cost of high cost medications
includes the cost of the drugs and dispensing services.
\4\All quantities shown are tablets unless otherwise stated. The
third party charge is only for the strengths and the dosage cited.
Charges will vary if the strengths and dosage are changed. The
method of computing standards costs to be charged for high cost
medications is actual cost to the pharmacy, plus a 30 percent
dispensing fee. Only medications listed in this schedule may be
billed. If a different dose is issued for a medication that is
listed, only bill if the cost is $100 or more.
\5\The attending physician is to complete the common procedure
terminology code to indicate the appropriate procedure followed
during cosmetic surgery.
\6\Cosmetic surgery rates will be charged for dependents of
active duty members, retirees, and their dependents and survivors.
The patient shall be charged the rate as specified in the FY 1994
reimbursable rates for an episode of care. The charges for elective
cosmetic surgery are at the full reimbursement rate (designated as
the Other rate--in Section I, ``Inpatient and Outpatient Rates'' and
Section II, ``Per Outpatient Visit''). The patient will be
responsible for both the cost of the implant(s) and prescribed
rates.
Note: The implants and procedures used for the augmentation
mammoplasty are in compliance with Federal Drug Administration
guidelines.
\7\Each regional lipectomy will carry a separate charge. Regions
include head and neck, abdomen, flanks, and hips.
\8\These procedures are inclusive in the minor skin lesions.
However, CHAMPUS separates them as noted here. All charges are for
the entire treatment regardless of the number of visits required.
Dated: April 7, 1994.
Patricia L. Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 94-8728 Filed 4-11-94; 8:45 am]
BILLING CODE 5000-04-M
