[Federal Register Volume 80, Number 29 (Thursday, February 12, 2015)]
[Notices]
[Pages 7844-7846]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-02898]
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DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE; Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS); Fiscal Year 2015 Diagnosis Related Group (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 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 data
necessary to update the FY 2015 rates.
DATES: Effective Dates: The rates, weights, and Medicare PPS changes
which affect the TRICARE DRG-based payment system contained in this
notice are effective for discharges occurring on or after October 1,
2014.
ADDRESSES: Defense Health Agency, TRICARE, Medical Benefits and
Reimbursement Office, 16401 East Centretech Parkway, Aurora, CO 80011-
9066.
FOR FURTHER INFORMATION CONTACT: Amber L. Butterfield, Medical Benefits
and Reimbursement Office, TRICARE, telephone (303) 676-3565.
Questions regarding payment of specific claims under the TRICARE
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, is that the TRICARE
DRG-based payment system is modeled on the Medicare PPS, and that,
whenever practicable, the TRICARE system will follow the same rules
that apply to the Medicare PPS. The Centers for Medicare and Medicaid
Services (CMS) publishes these changes annually in the Federal Register
and discusses in detail the impact of the changes.
In addition, this notice updates the rates and weights in
accordance with our previous final rules. The actual changes we are
making, along with a description of their relationship to the Medicare
PPS, are detailed below.
I. Medicare PPS Changes Which Affect the TRICARE DRG-Based Payment
System
Following is a discussion of the changes CMS has made to the
Medicare PPS that affect the TRICARE DRG-based payment system.
A. DRG Classifications
Under both the Medicare PPS and the TRICARE 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
[[Page 7845]]
information (that is, sex, age, and discharge status). The Grouper used
for the TRICARE DRG-based payment system is the same as the current
Medicare Grouper with two modifications. The TRICARE system has
replaced Medicare DRG 435 with two age-based DRGs (900 and 901), and
has implemented thirty-four (34) neonatal DRGs in place of Medicare
DRGs 385 through 390. For admissions occurring on or after October 1,
2001, DRG 435 has been replaced by DRG 523. The TRICARE system has
replaced DRG 523 with the two age-based DRGs (900 and 901). 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 Major Diagnostic Category (MDC) 15 occur before
assignment of the pre-MDC DRGs. This resulted in all neonate
tracheostomies and organ transplants to be grouped to MDC 15 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 pre-MDC DRGs and to assign patients to pre-MDC DRGs 480, 103,
and 495 before assignment to MDC 15 DRGs and the neonatal DRGs. For
admissions occurring on or after October 1, 2001, DRGs 512 and 513 were
added to the pre-MDC DRGs, between DRGs 480 and 103 in the TRICARE
Grouper hierarchy logic. For admissions occurring on or after October
1, 2004, DRG 483 was deleted and replaced with DRGs 541 and 542,
splitting the assignment of cases on the basis of the performance of a
major operating room procedure. The description for DRG 480 was changed
to ``Liver Transplant and/or Intestinal Transplant'', and the
description for DRG 103 was changed to ``Heart/Heart Lung Transplant or
Implant of Heart Assist System''. For FY 2007, CMS implemented
classification changes, including surgical hierarchy changes. The
TRICARE Grouper incorporated all changes made to the Medicare Grouper,
with the exception of the pre-surgical hierarchy changes, which will
remain the same as FY 2006. For FY 2008, Medicare implemented their
Medicare-Severity DRG (MS-DRG) based payment system. TRICARE, however,
continued with the Centers for Medicare and Medicaid Services DRG-based
(CMS-DRG) payment system for FY 2008. For FY 2009, the TRICARE/CHAMPUS
DRG-based payment system shall be modeled on the MS-DRG system, with
the following modifications.
The MS-DRG system consolidated the 43 pediatric CMS DRGs that were
defined based on age less than or equal to 17 into the most clinically
similar MS-DRGs. In their Inpatient Prospective Payment System final
rule for MS-DRGs, Medicare stated for their population these pediatric
CMS DRGs contained a very low volume of Medicare patients. At the same
time, Medicare encouraged private insurers and other non-Medicare
payers to make refinements to MS-DRGs to better suit the needs of the
patients they serve. Consequently, TRICARE finds it appropriate to
retain the pediatric CMS-DRGs for our population. TRICARE is also
retaining the TRICARE-specific DRGs for neonates and substance use.
For FY09, TRICARE will use the MS-DRG v26.0 pre-MDC hierarchy, with
the exception that MDC 15 is applied after DRG 011-012 and before MDC
24.
For FY10, there are no additional or deleted DRGs.
For FY 11, the added DRGs and deleted DRGs are the same as those
included in CMS' final rule published on August 16, 2010 (75 FR 50041-
50677). That is, DRG 009 is deleted; DRGs 014 and 015 are being added.
For FY 12, the added DRGs and deleted DRGs are the same as those
included in CMS' final rule published on August 18, 2011 (76 FR 51476-
51846). That is, DRG 015 is deleted; DRGs 016 and 017 are being added.
For FY 2013 there are no new, revised, or deleted DRGs.
For FY 2014 there are no new, revised, or deleted DRGs.
For FY 2015 the added, deleted and revised DRGs are the same as
those included in the CMS' final rule published on August 22, 2014, (79
FR 49853-50536), with the exception of endovascular cardiac valve
replacement for which CMS added DRGs 266/267. The TRICARE Grouper
already has DRGs 266/267 assigned to a pediatric procedure therefore
TRICARE added DRGs 317/318, respectively, for endovascular cardiac
valve replacement.
B. Wage Index and Medicare Geographic Classification Review Board
Guidelines
TRICARE will continue to use the same wage index amounts used for
the Medicare PPS. TRICARE will also duplicate all changes with regard
to the wage index for specific hospitals that are redesignated by the
Medicare Geographic Classification Review Board. In addition, TRICARE
will continue to utilize the out commuting wage index adjustment.
C. Revision of the Labor-Related Share of the Wage Index
TRICARE is adopting CMS' percentage of labor related share of the
standardized amount. For wage index values greater than 1.0, the labor
related portion of the Adjusted Standardized Amount (ASA) shall
continue to equal 69.6 percent. For wage index values less than or
equal to 1.0 the labor related portion of the ASA shall continue to
equal 62 percent.
D. Hospital Market Basket
TRICARE will update the adjusted standardized amounts according to
the final updated hospital market basket used for the Medicare PPS for
all hospitals subject to the TRICARE DRG-based payment system according
to CMS' August 22, 2014, final rule. For FY 2015, the market basket is
2.9 percent. Note: Medicare's FY 2015 market basket index adjusts
according to hospitals' compliance with quality data and electronic
health record meaningful use submissions. These adjustments do not
apply to the TRICARE Program.
E. Outlier Payments
Since TRICARE does not include capital payments in our DRG-based
payments (TRICARE reimburses hospitals for their capital costs as
reported annually to the contractor on a pass through basis), we will
use the fixed loss cost outlier threshold calculated by CMS for paying
cost outliers in the absence of capital prospective payments. For FY
2015, the TRICARE fixed loss cost outlier threshold is based on the sum
of the applicable DRG-based payment rate plus any amounts payable for
Indirect Medical Education (IDME) plus a fixed dollar amount. Thus, for
FY 2015, in order for a case to qualify for cost outlier payments, the
costs must exceed the TRICARE DRG base payment rate (wage adjusted) for
the DRG plus the IDME payment (if applicable) plus $22,705 (wage
adjusted). The marginal cost factor for cost outliers continues to be
80 percent.
F. National Operating Standard Cost as a Share of Total Costs
The FY 2015 TRICARE National Operating Standard Cost as a Share of
Total Costs (NOSCASTC) used in calculating the cost outlier threshold
is 0.922. TRICARE uses the same methodology as CMS for calculating the
NOSCASTC; however, the variables are different because TRICARE uses
national cost to charge ratios while CMS uses hospital specific cost to
charge ratios.
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G. Indirect Medical Education (IDME) Adjustment
Passage of the Medical Modernization Act of 2003 modified the
formula multipliers to be used in the calculation of IDME adjustment
factor. Since the IDME formula used by TRICARE does not include
disproportionate share hospitals (DSHs), the variables in the formula
are different than Medicare's, however; the percentage reductions that
will be applied to Medicare's formula will also be applied to the
TRICARE IDME formula. The multiplier for the IDME adjustment factor for
TRICARE for FY 2015 is 1.02.
H. Cost to Charge Ratio
TRICARE uses a national Medicare cost-to-charge ratio (CCR). For FY
2015, the Medicare CCR used for the TRICARE DRG-based payment system
for acute care hospitals and neonates will be 0.2726. This is based on
a weighted average of the hospital-specific Medicare CCRs (weighted by
the number of Medicare discharges) after excluding hospitals not
subject to the TRICARE DRG system (Sole Community Hospitals, Indian
Health Service hospitals, and hospitals in Maryland). The Medicare CCR
is used to calculate cost outlier payments, except for children's
hospitals. The Medicare CCR has been increased by a factor of 1.0065 to
include an additional allowance for bad debt. The 1.0065 factor
reflects the provisions of the Middle Class Tax Relief and Job Creation
Act of 2012. For children's hospital cost outliers, the CCR used is
0.2939.
I. Pricing of Claims
The final rule published on May 21, 2014, (79 FR 29085-29088) set
forth all final claims with discharge dates of October 1, 2014, or
later and reimbursed under the TRICARE DRG-Based payment system, are to
be priced using the rules, weights and rates in effect on as of the
date of discharge. Prior to this, all final claims were priced using
the rules, weights and rates in effective as of the date of admission.
J. Updated Rates and Weights
The updated rates and weights are accessible through the Internet
at http://www.tricare.mil/drgrates. The implementing regulations for
the TRICARE/CHAMPUS DRG-based payment system are in 32 CFR part 199.
Dated: February 6, 2015.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2015-02898 Filed 2-11-15; 8:45 am]
BILLING CODE 5001-06-P