[Federal Register Volume 65, Number 211 (Tuesday, October 31, 2000)]
[Notices]
[Pages 65024-65032]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-27726]
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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 Public Law 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 2001 Department of Defense (DoD) reimbursement rates for
inpatient, outpatient, and other services are provided in accordance
with Title 10, United States Code, section 1095. Due to size, the
sections containing the Drug Reimbursement Rates (section IV.C.) and
the rates for Ancillary Services Requested by Outside Providers
(section IV.D.) are not included in this package. Those rates are
available from the TRICARE Management Activity's Uniform Business
Office website, http://www.tricare.osd.mil/ebc/rm/rm__home.html. The
medical and dental service rates in this package (including the rates
for ancillary services and other procedures requested by outside
providers) are effective October 1, 2000. Pharmacy rates are updated on
an as needed basis.
2. Health and Human Services
The FY 2001 tortiously liable rates for Indian Health Service
health facilities are based on Medicare cost reports. The obligations
for the Indian Health Service hospitals participating in the cost
report
[[Page 65025]]
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 the Contract Health fund, that were used to support the
inpatient and outpatient workload. 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.
Separate rates per inpatient day and outpatient visit were computed
for Alaska and the rest of the United States. This gives proper weight
to the higher cost of operating medical facilities in Alaska.
1. Department of Defense
For the Department of Defense, effective October 1, 2000 and
thereafter:
Inpatient, Outpatient and Other Rates and Charges
1. Inpatient Rates12
----------------------------------------------------------------------------------------------------------------
International Interagency and
Military other Federal Other (full/
Per inpatient day Education and agency sponsored third party)
Training (IMET) patients
----------------------------------------------------------------------------------------------------------------
A. Burn Center......................................... $4,144.00 $5,694.00 $6,016.00
B. Surgical Care Services (Cosmetic Surgery)........... 1,895.00 2,604.00 2,752.00
C. All Other Inpatient Services (Based on Diagnosis
Related Groups (DRG) \3\..............................
----------------------------------------------------------------------------------------------------------------
Average FY01 Direct Care Inpatient Reimbursement Rates
----------------------------------------------------------------------------------------------------------------
Other (full/
Adjusted standard amount IMET Interagency third party)
----------------------------------------------------------------------------------------------------------------
Large Urban............................................... $2,986.00 $5,712.00 $6,002.00
Other Urban/Rural......................................... 3,468.00 6,633.00 7,004.00
Overseas.................................................. 3,872.00 9,045.00 9,489.00
----------------------------------------------------------------------------------------------------------------
2. Overview
The FY01 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.
Each large urban or other urban/rural MTF providing inpatient care has
their own ASA rate--The MTF-specific ASA rate is the published ASA rate
adjusted for area wage differences and indirect medical education (IME)
for the discharging hospital (see Attachment 1). The MTF-specific ASA
rate submitted on the claim is the rate that payers will use for
reimbursement purposes. For a more complete description of the
development of MTF-ASAs and how they are applied refer to the ASA
Primer at http://www.tricare.osd.mil/org/pae/asa--primer/asa--
primer1.html.
Overseas MTFs use the rates specified in paragraph I. C. 1. For
providers performing inpatient care at a civilian facility for a DoD
beneficiary, see note 3. 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 non-teaching hospital (Reynolds Army
Community Hospital) in an Other Urban/Rural area.
a. The cost to be recovered is the military treatment facility's
cost for medical services provided. 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 2.2244. (DRG statistics
shown are from FY 1999.)
c. The MTF-applied ASA rate is $6,831 (Reynolds Army Community
Hospital's third party rate as shown in Attachment 1).
d. The MTF cost to be recovered is the RWP factor (2.2244) in
subparagraph 3.b., above, multiplied by the amount ($6,831) in
subparagraph 3.c., above.
e. Cost to be recovered is $15,195.
[[Page 65026]]
Figure 1.--Third Party Billing Examples
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Arithmetic Geometric Short stay Long stay
DRG number DRG description DRG weight mean LOS mean LOS threshold threshold
--------------------------------------------------------------------------------------------------------------------------------------------------------
020................................... Nervous System Infection Except Viral 2.2244 8.3 5.8 1 29
Meningitis.
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Area wage IME MTF-applied
Hospital Location rate index adjustment Group ASA ASA
--------------------------------------------------------------------------------------------------------------------------------------------------------
Reynolds Army Community Hospital.............. Other urban/rural............................. .9156 1.0 $7,004 $6,831
--------------------------------------------------------------------------------------------------------------------------------------------------------
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Length of Relative weighted product
Patient stay Days above ----------------------------------- TPC
(days) threshold Inlier\*\ Outlier\**\ Total Amount\***\
----------------------------------------------------------------------------------------------------------------
#1..................................... 7 0 2.2244 000 2.2244 $15,195
#2..................................... 21 0 2.2244 000 2.2244 $15,195
#3..................................... 35 6 2.2244 .7594 2.9838 $20,382
----------------------------------------------------------------------------------------------------------------
\*\ 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 (2.2244/5.8) x (35-29)
= .33 (.38352) x 6 (take out to five decimal places)
= .12656 x 6 (carry to five decimal places)
= .7594 (carry to four decimal places)
\***\ MTF-Applied ASA x Total RWP
II. Outpatient Rates
[Per Visit 1,2]
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Interagency and
International other federal
MEPRS code \4\ Clinical service military agency Other (full/
education and sponsored third party)
training (IMET) patients
----------------------------------------------------------------------------------------------------------------
A. Medical Care:
BAA........................ Internal Medicine.............. $147.00 $204.00 $216.00
BAB........................ Allergy........................ 80.00 111.00 117.00
BAC........................ Cardiology..................... 129.00 180.00 190.00
BAE........................ Diabetic....................... 105.00 146.00 154.00
BAF........................ Endocrinology (Metabolism)..... 151.00 210.00 222.00
BAG........................ Gastroenterology............... 183.00 255.00 269.00
BAH........................ Hematology.................... 286.00 398.00 420.00
BAI........................ Hypertension.................. 216.00 301.00 318.00
BAJ........................ Nephrology.................... 221.00 307.00 324.00
BAK........................ Neurology..................... 165.00 229.00 242.00
BAL........................ Outpatient Nutrition.......... 69.00 96.00 101.00
BAM........................ Oncology...................... 201.00 280.00 295.00
BAN........................ Pulmonary Disease............. 186.00 259.00 273.00
BAO........................ Rheumatology.................. 139.00 194.00 205.00
BAP........................ Dermatology................... 115.00 160.00 169.00
BAQ........................ Infectious Disease............ 181.00 252.00 266.00
BAR........................ Physical Medicine............. 115.00 160.00 169.00
BAS........................ Radiation Therapy............. 169.00 235.00 248.00
BAT........................ Bone Marrow Transplant........ 190.00 264.00 279.00
BAU........................ Genetic....................... 330.00 460.00 485.00
BAV........................ Hyperbaric.................... 344.00 480.00 506.00
B. Surgical Care:
BBA........................ General Surgery............... 215.00 299.00 316.00
BBB........................ Cardiovascular and Thoracic 419.00 584.00 616.00
Surgery.
BBC........................ Neurosurgery................... 249.00 347.00 366.00
BBD........................ Ophthalmology................. 130.00 181.00 191.00
BBE........................ Organ Transplant.............. 1,106.00 1,541.00 1,625.00
BBF........................ Otolaryngology................ 149.00 207.00 219.00
BBG........................ Plastic Surgery............... 168.00 235.00 247.00
BBH........................ Proctology.................... 125.00 174.00 184.00
BBI........................ Urology....................... 164.00 228.00 240.00
BBJ........................ Pediatric Surgery............. 89.00 125.00 131.00
BBK........................ Peripheral Vascular Surgery... 98.00 137.00 145.00
BBL........................ Pain Management............... 138.00 193.00 203.00
BBM........................ Vascular and Interventional 493.00 687.00 724.00
Radiology.
C. Obstetrical and
Gynecological (OB-GYN) Care:
BCA........................ Family Planning............... 76.00 106.00 111.00
[[Page 65027]]
BCB........................ Gynecology.................... 127.00 177.00 187.00
BCC........................ Obstetrics.................... 104.00 144.00 152.00
BCD........................ Breast Cancer Clinic........... 240.00 334.00 352.00
D. Pediatric Care:
BDA........................ Pediatric..................... 92.00 128.00 134.00
BDB........................ Adolescent.................... 83.00 115.00 121.00
BDC........................ Well Baby..................... 63.00 87.00 92.00
E. Orthopaedic Care:
BEA........................ Orthopaedic................... 143.00 200.00 211.00
BEB........................ Cast.......................... 89.00 123.00 130.00
BEC........................ Hand Surgery.................. 76.00 106.00 112.00
BEE........................ Orthotic Laboratory........... 93.00 130.00 137.00
BEF........................ Podiatry...................... 80.00 112.00 118.00
BEZ........................ Chiropractic.................. 38.00 53.00 55.00
F. Psychiatric and/or Mental
Health Care:
BFA........................ Psychiatry..................... 165.00 230.00 242.00
BFB........................ Psychology.................... 115.00 160.00 169.00
BFC........................ Child Guidance................ 92.00 128.00 135.00
BFD........................ Mental Health................. 148.00 206.00 217.00
BFE........................ Social Work................... 147.00 205.00 217.00
BFF........................ Substance Abuse............... 141.00 197.00 208.00
G. Family Practice/Primary
Medical Care:
BGA........................ Family Practice............... 107.00 149.00 157.00
BHA........................ Primary Care.................. 109.00 151.00 160.00
BHB........................ Medical Examination........... 111.00 155.00 163.00
BHC........................ Optometry..................... 72.00 100.00 105.00
BHD........................ Audiology..................... 52.00 73.00 77.00
BHE........................ Speech Pathology.............. 122.00 170.00 180.00
BHF........................ Community Health.............. 85.00 118.00 125.00
BHG........................ Occupational Health........... 108.00 151.00 159.00
BHH........................ TRICARE Outpatient............ 74.00 104.00 109.00
BHI........................ Immediate Care................ 161.00 225.00 237.00
H. Emergency Medical Care:
BIA........................ Emergency Medical............. 173.00 242.00 255.00
I. Flight Medical Care:
BJA........................ Flight Medicine............... 124.00 173.00 182.00
J. Underseas Medical Care:
BKA........................ Underseas Medicine............ 77.00 108.00 114.00
K. Rehabilitative Services:
BLA........................ Physical Therapy.............. 56.00 79.00 83.00
BLB........................ Occupational Therapy.......... 75.00 104.00 110.00
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III. Ambulatory Procedure Visit (APV)
[Per visit \5\]
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Interagency and
International other federal
MEPRS code \4\ Clinical service military agency Other (full/
education and sponsored third party)
training (IMET) patients
----------------------------------------------------------------------------------------------------------------
Medical Care:
BB.......................... Surgical Care.................. $1,313.00 $1,829.00 $1,929.00
BE.......................... Orthopaedic Care............... 1,664.00 2,319.00 2,446.00
All Other................... B clinics other than BB and BE, 378.00 527.00 556.00
to include those B clinics
where:.
1. There is an APU established
within DoD guidelines AND--
2. There is a rate established
for that clinic in section II.
Some B clinics, such as BF,
BI, BJ and BL, perform the
type of services where the
establishment of an APU would
not be within appropriate
clinical guidelines.
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[[Page 65028]]
IV. Other Rates and Charges \1\ \2\
----------------------------------------------------------------------------------------------------------------
Interagency and
International other federal
MEPRS code \4\ Clinical service military agency Other (full/
education and sponsored third party)
training (IMET) patients
----------------------------------------------------------------------------------------------------------------
A. Per Each:
FBI......................... Immunization................... $22.00 $31.00 $32.00
B. Family Member Rate: $11.45
(formerly Military Dependents
Rate)
C. Reimbursement Rates For
Drugs Requested By Outside
Providers: \6\ \15\
D. Ancillary Services Requested
by an Outside Provider--Per
Procedure: \7\ \15\
DB.......................... Laboratory procedures requested 15.00 22.00 23.00
by an outside provider CPT '00
Weight Multiplier.
DC, DI...................... Radiology procedures requested 79.00 115.00 120.00
by an outside provider CPT '00
Weight Multiplier.
E. Dental Rate--Per Procedure:
\11\
Dental Services ADA code weight 73.00 112.00 117.00
multiplier.
F. Ambulance Rate--Per Hour:
\12\
FEA......................... Ambulance...................... 81.00 113.00 120.00
G. AirEvac Rate--Per Trip (24
hour period): \13\
AirEvac Services--Ambulatory 339.00 473.00 499.00
AirEvac Services--Litter....... 989.00 1,379.00 1,454.00
H. Observation Rate--Per hour--
\14\
Observation Services--Hour..... 20.00 28.00 30.00
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V. Elective Cosmetic Surgery Procedures and Rates
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International Current
classification procedural
Cosmetic surgery procedure diseases (ICD- terminology FY 2001 Charge \9\ Amount of charge
9) (CPT) \8\
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Mammaplasty--augmentation........... 85.50 19325 Inpatient Surgical (a)
Care Per Diem or APV (b)
85.32 19324
85.31 19318
Mastopexy........................... 85.60 19316 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Facial.............................. 86.82 15824 Inpatient Surgical (a)
Care Per Diem or APV (b)
Rhytidectomy........................ 86.22
Blepharoplasty...................... 08.70 15820 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
08.44 15821
15822
15823
Mentoplasty (Augmentation/or 76.68 21208 Inpatient Surgical (a)
Reduction). Care Per Diem APV or (b)
applicable Outpatient (c)
Clinic Rate
76.67 21209
Abdominoplasty...................... 86.83 15831 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Lipectomy........................... 86.83 15876 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Suction per region 10............... 15877
15878
15879
Rhinoplasty......................... 21.87 30400 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
21.86 30410
[[Page 65029]]
Scar Revisions beyond CHAMPUS....... 86.84 1578__ Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Mandibular or Maxillary 76.41 21194 Inpatient Surgical (a)
Repositioning. Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Dermabrasion........................ 86.25 15780 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Hair Restoration.................... 86.64 15775 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Removing Tattoos.................... 86.25 15780 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Chemical Peel....................... 86.24 15790 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
Arm/Thigh: Dermolipectomy........... 86.83 15836/ Inpatient Surgical (a)
Care Per Diem or APV (b)
APV or applicable (b)
Outpatient Clinic (c)
Rate (e)
Refractive surgery.................. ............... 15832
Radial Keratotomy................... ............... 65771
Other Procedure (if applies to ............... 66999
laser or other.
refractive surgery).............
Otoplasty........................... ............... 69300 APV or applicable (b)
Outpatient Clinic (c)
Rate
Brow Lift........................... 86.3 15839 Inpatient Surgical (a)
Care Per Diem or APV (b)
or applicable (c)
Outpatient Clinic
Rate
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Notes on Cosmetic Surgery Charges
\a\ Per diem charges for inpatient surgical care services are
listed in section I.B. (See notes 8 through 10, below, for further
details on reimbursable rates.)
\b\ Charges for ambulatory procedure visits (formerly same day
surgery) are listed in section III. (See notes 8 through 10, 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.
\d\ Charge is solely determined by the location of where the
care is provided and is not to be based on any other criteria. An
APV rate can only be billed if the location has been established as
an APU following all required DoD guidelines and instructions.
\e\ Refer to HA Policy on Vision Correction Via Laser Surgery
For Non-Active Duty Beneficiaries, April 7, 2000 for further
guidance on billing for these services. It can be downloaded from
http://www.tricare.osd.mil/policy/2000poli.htm.
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.
\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.
MTFs without inpatient services, whose providers are performing
inpatient care in a civilian facility for a DoD beneficiary, can
bill payers the percentage of the charge that represents
professional services as provided in \1\ above. The ASA rate used in
these cases, based on the absence of a ASA rate for the facility,
will be based on the average ASA rate for the type of metropolitan
statistical area the MTF resides, large urban, other urban/rural, or
overseas. (see paragraph I.C.1.). The Uniform Business Office must
receive documentation of care provided in order to produce a bill.
\4\ The Medical Expense and Performance Reporting System (MEPRS)
code is a three
[[Page 65030]]
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\ 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 and BE APV rates are to be used only 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 or BE. In addition, APV rates may only be
utilized for clinics where there is a clinic rate established. For
example, BLC, Neuromuscular Screening, no longer has an established
rate. Therefore, an APU can not be defined and an APV can not be
billed for this clinic.
\6\ 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 (e.g.,
physicians and dentists). Eligible beneficiaries (family members or
retirees with medical insurance) are not liable personally 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 includes the DoD-wide average cost of the drug, calculated
by National Drug Code (NDC) number. The prescription charge is
calculated by multiplying the number of units (e.g., tablets or
capsules) by the unit cost and adding $6.00 for the cost of
dispensing the prescription. Dispensing costs include overhead,
supplies and labor, etc. to fill the prescription.
The list of drug reimbursement rates is too large to include in
this document. Those rates are available from the TRICARE Management
Activity's Uniform Business Office website, http://
www.tricare.osd.mil/ebc/rm/rm__home.html.
\7\ The list of FY 2001 rates for ancillary services requested
by outside providers and obtained at a Military Treatment Facility
is too large to include in this document. Those rates are available
from the TRICARE Management Activity's Uniform Business Office
website, http://www.tricare.osd.mil/ebc/rm/rm__home.html.
Charges for ancillary services requested by an outside provider
(e.g., physicians and dentists) 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 00) code by
either the laboratory or radiology multiplier (section IV.D.).
Radiology procedures performed by Nuclear Medicine use the same
methodology as Radiology for calculating a charge because their
workload and expenses are included in the establishment of the
Radiology multiplier.
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.
\8\ The attending physician is to complete the CPT 00 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.
\9\ 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 V. The patient shall be charged the rate as
specified in the FY 2001 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., 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.)
\10\ Each regional lipectomy shall carry a separate charge.
Regions include head and neck, abdomen, flanks, and hips.
\11\ Dental service rates are based on a dental rate multiplied
by the DoD established weight for the American Dental Association
(ADA) code performed. For example, for ADA code 00270, bite wing
single film, the weight is 0.15. The weight of 0.15 is multiplied by
the appropriate rate, IMET, IAR, or Full/Third Party rate to obtain
the charge. If the Full/Third Party rate is used, then the charge
for this ADA code will be $17.55 ($117 x .15 = $17.55).
The list of FY 2001 ADA codes and weights for dental services is
too large to include in this document. Those rates are available
from the TRICARE Management Activity's Uniform Business Office
website, http://www.tricare.osd.mil/ebc/rm/rm_home.html.
\12\ Ambulance charges shall be based on hours of service in 15
minute increments. The rates listed in section IV.F. 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).
\13\ Air in-flight medical care reimbursement charges are
determined by the status of the patient (ambulatory or litter) and
are per patient during a 24 hour period. 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.
\14\ Observation Services are billed at the hourly charge. Begin
counting when the patient is placed in the observation bed and round
to the nearest hour. For example, if a patient has received one hour
and 20 minutes of observation, then you bill for one hour of
service. If the status of a patient changes to inpatient, the
charges for observation services are added to the DRG assigned to
the case and not separately billed. 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.
\15\ Final rule 32 CFR part 220, published February 16, 2000,
eliminated the dollar threshold for high cost ancillary services and
the associated term ``high cost ancillary service.'' The phrase
``high cost ancillary service'' is replaced with the phrase
``ancillary services requested by an outside provider.'' The
elimination of the threshold also eliminated 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) exceeds
$25.00. The elimination of the threshold is effective as per date
stated in final rule 32 CFR Part 220.
[[Page 65031]]
Attachment 1.--Adjusted Standardized Amounts (ASA) By Military Treatment Facility
----------------------------------------------------------------------------------------------------------------
Full cost Interagency IMET TPC
DMISID MTF name Serv rate rate rate rate
----------------------------------------------------------------------------------------------------------------
0003................ Lyster AH--Ft. Rucker......... A.............. $6,637 $6,286 $3,286 $6,637
0004................ 502nd Med Grp--Maxwell AFB.... F.............. 6,984 6,614 3,458 6,984
0005................ Bassett ACH--Ft. Wainwright... A.............. 7,152 6,774 3,541 7,152
0006................ 3rd Med Grp--Elmendorf AFB.... F.............. 7,041 6,668 3,486 7,041
0009................ 56th Med Grp--Luke AFB........ F.............. 5,986 5,697 2,978 5,986
0014................ 60th Med Grp--Travis AFB...... F.............. 9,912 9,387 4,907 9,912
0018................ 30th Med Grp--Vandenberg AFB.. F.............. 7,035 6,663 3,483 7,035
0019................ 95th Med Grp--Edwards AFB..... F.............. 7,004 6,633 3,468 7,004
0024................ NH Camp Pendleton............. N.............. 7,614 7,245 3,787 7,614
0028................ NH Lemoore.................... N.............. 6,997 6,627 3,465 6,997
0029................ NH San Diego.................. N.............. 9,744 9,273 4,847 9,744
0030................ NH Twenty Nine Palms.......... N.............. 6,111 5,815 3,039 6,111
0032................ Evans ACH--Ft. Carson......... A.............. 6,946 6,578 3,439 6,946
0033................ 10th Med Grp--USAF Academy.... F.............. 6,994 6,623 3,463 6,994
0037................ Walter Reed AMC-- Washington A.............. 9,010 8,574 4,482 9,010
DC.
0038................ NH Pensacola.................. N.............. 8,939 8,465 4,426 8,939
0039................ NH Jacksonville............... N.............. 7,537 7,173 3,749 7,537
0042................ 96th Med Grp--Eglin AFB....... F.............. 8,309 7,869 4,114 8,309
0043................ 325th Med Grp--Tyndall AFB.... F.............. 7,002 6,631 3,467 7,002
0045................ 6th Med Grp--MacDill AFB...... F.............. 5,991 5,702 2,980 5,991
0047................ Eisenhower AMC--Ft. Gordon.... A.............. 8,550 8,098 4,233 8,550
0048................ Martin ACH--Ft. Benning....... A.............. 7,987 7,564 3,954 7,987
0049................ Winn ACH--Ft. Stewart......... A.............. 6,644 6,292 3,289 6,644
0052................ Tripler AMC--Ft. Shafter...... A.............. 9,533 9,029 4,720 9,533
0053................ 366th Med Grp--Mountain Home F.............. 6,982 6,612 3,457 6,982
AFB.
0055................ 375th Med Grp--Scott AFB...... F.............. 7,625 7,256 3,793 7,625
0056................ NH Great Lakes................ N.............. 6,063 5,770 3,016 6,063
0057................ Irwin AH--Ft. Riley........... A.............. 6,521 6,176 3,229 6,521
0060................ Blanchfield ACH--Ft. Campbell. A.............. 6,605 6,255 3,270 6,605
0061................ Ireland ACH--Ft. Knox......... A.............. 6,829 6,467 3,381 6,829
0064................ Bayne-Jones ACH--Ft. Polk..... A.............. 6,573 6,225 3,254 6,573
0066................ 89th Med Grp--Andrews AFB..... F.............. 8,062 7,672 4,010 8,062
0067................ NNMC Bethesda................. N.............. 9,786 9,313 4,868 9,786
0073................ 81st Med Grp--Keesler AFB..... F.............. 8,772 8,308 4,343 8,772
0075................ Wood ACH--Ft. Leonard Wood.... A.............. 6,539 6,193 3,237 6,539
0078................ 55th Med Grp--Offutt AFB...... F.............. 8,697 8,236 4,306 8,697
0079................ 99th Med Grp--Nellis AFB...... F.............. 6,002 5,712 2,986 6,002
0083................ 377th Med Grp--Kirtland AFB... F.............. 6,971 6,602 3,452 6,971
0084................ 49th Med Grp--Holloman AFB... F.............. 7,004 6,633 3,468 7,004
0086................ Keller ACH--West Point........ A.............. 7,296 6,909 3,612 7,296
0089................ Womack AMC--Ft. Bragg......... A.............. 7,817 7,403 3,870 7,817
0091................ NH Camp LeJeune............... N.............. 6,744 6,387 3,339 6,744
0092................ NH Cherry Point............... N.............. 6,788 6,429 3,361 6,788
0093................ 319th Med Grp--Grand Forks F.............. 7,032 6,660 3,482 7,032
AFB.
0094................ 5th Med Grp--Minot AFB........ F.............. 6,857 6,494 3,395 6,857
0095................ 74th Med Grp--Wright- F............. 10,371 9,822 5,135 10,371
Patterson AFB.
0096................ 72nd Med Grp--Tinker AFB...... F.............. 6,001 5,711 2,985 6,001
0097................ 97th Med Grp--Altus AFB....... F.............. 6,976 6,607 3,454 6,976
0098................ Reynolds ACH--Ft. Sill........ A.............. 6,831 6,469 3,382 6,831
0100................ NH Newport.................... N.............. 6,002 5,712 2,986 6,002
0101................ 20th Med Grp--Shaw AFB........ F.............. 6,964 6,595 3,448 6,964
0103................ NH Charleston................. N.............. 6,879 6,514 3,406 6,879
0104................ NH Beaufort................... N.............. 6,871 6,507 3,402 6,871
0105................ Moncrief ACH--Ft. Jackson..... A.............. 6,961 6,592 3,446 6,961
0106................ 28th Med Grp--Ellsworth AFB... F.............. 6,939 6,572 3,436 6,939
0108................ Wm Beaumont AMC--Ft. Bliss.... A.............. 8,329 7,888 4,124 8,329
0109................ Brooke AMC--Ft. Sam Houston.. A.............. 8,511 8,099 4,233 8,511
0110................ Darnall AH--Ft. Hood.......... A.............. 8,606 8,151 4,261 8,606
0112................ 7th Med Grp--Dyess AFB........ F.............. 6,892 6,528 3,413 6,892
0113................ 82nd Med Grp--Sheppard AFB.... F.............. 6,903 6,537 3,418 6,903
0117................ 59th Med Wing--Lackland AFB... F.............. 8,640 8,222 4,297 8,640
0119................ 75th Med Grp--Hill AFB........ F.............. 5,983 5,693 2,976 5,983
0120................ 1st Med Grp--Langley AFB...... F.............. 5,954 5,666 2,962 5,954
0121................ McDonald ACH--Ft. Eustis...... A.............. 5,649 5,376 2,810 5,649
0123................ Dewitt AH--Ft. Belvoir........ A.............. 8,237 7,839 4,097 8,237
0124................ NH Portsmouth................. N.............. 7,469 7,107 3,715 7,469
0125................ Madigan AMC--Ft. Lewis........ A.............. 11,018 10,435 5,455 11,018
0126................ NH Bremerton.................. N.............. 8,165 7,733 4,043 8,165
0127................ NH Oak Harbor................. N.............. 6,283 5,979 3,125 6,283
0129................ 90th Med Grp--F.E. Warren AFB. F.............. 6,989 6,619 3,460 6,989
[[Page 65032]]
0131................ Weed ACH--Ft. Irwin........... A.............. 7,003 6,633 3,467 7,003
0449................ 24th Med Grp--Howard.......... F.............. 9,489 9,045 3,872 9,489
0606................ 95th CSH--Heidelberg.......... A.............. 9,489 9,045 3,872 9,489
0607................ Landstuhl Rgn MC.............. A.............. 9,489 9,045 3,872 9,489
0609................ 67th CSH--Wurzburg............ A.............. 9,489 9,045 3,872 9,489
0612................ 121st Gen Hosp--Seoul......... A.............. 9,489 9,045 3,872 9,489
0615................ NH Guantanamo Bay............. N.............. 9,489 9,045 3,872 9,489
0616................ NH Roosevelt Roads............ N.............. 9,489 9,045 3,872 9,489
0617................ NH Naples..................... N.............. 9,489 9,045 3,872 9,489
0618................ NH Rota....................... N.............. 9,489 9,045 3,872 9,489
0620................ NH Guam....................... N.............. 9,489 9,045 3,872 9,489
0621................ NH Okinawa.................... N.............. 9,489 9,045 3,872 9,489
0622................ NH Yokosuka................... N.............. 9,489 9,045 3,872 9,489
0623................ NH Keflavik................... N.............. 9,489 9,045 3,872 9,489
0624................ BH Sigonella.................. N.............. 9,489 9,045 3,872 9,489
0633................ 48th Med Grp--RAF Lakenheath.. F.............. 9,489 9,045 3,872 9,489
0635................ 39th Med Grp--Incirlik AB..... F.............. 9,489 9,045 3,872 9,489
0638................ 51st Med Grp--Osan AB......... F.............. 9,489 9,045 3,872 9,489
0639................ 35th Med Grp--Misawa.......... F.............. 9,489 9,045 3,872 9,489
0640................ 374th Med Grp--Yokota AB...... F.............. 9,489 9,045 3,872 9,489
0805................ 52nd Med Grp--Spangdahlem..... F.............. 9,489 9,045 3,872 9,489
0808................ 31st Med Grp--Aviano.......... F.............. 9,489 9,045 3,872 9,489
----------------------------------------------------------------------------------------------------------------
2. Department of Health and Human Services
For the Department of Health and Human Services, Indian Health
Service, effective October 1, 2000 and thereafter:
Hospital Care Inpatient Day
General Medical Care
Alaska--$1,837
Rest of the United States--$1,357
Outpatient Medical Treatment
Outpatient Visit
Alaska--$337
Rest of the United States--$189
For the period beginning October 1, 2000, the rates prescribed
herein superceded those established by the Director of the Office of
Management and Budget, November 1, 1999 (64 FR 58862).
Jacob J. Lew,
Director, Office of Management and Budget.
[FR Doc. 00-27726 Filed 10-30-00; 8:45 am]
BILLING CODE 3110-01-P