[Federal Register Volume 59, Number 145 (Friday, July 29, 1994)] [Unknown Section] [Page 0] From the Federal Register Online via the Government Publishing Office [www.gpo.gov] [FR Doc No: 94-18061] [[Page Unknown]] [Federal Register: July 29, 1994] ======================================================================= ----------------------------------------------------------------------- OFFICE OF MANAGEMENT AND BUDGET Cost of Hospital and Medical Care and 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 P.L. 87-693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to the Director of the Office of Management and Budget by Executive Order No. 11541 of July 1, 1970 (35 FR 10737), the revised set of Department of Defense 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 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: Department of Defense. Historic costs including purchases of supplies and equipment, base pay, allowances, permanent change of station costs, retirement pay and health benefits accrual costs, medical specialty pays and medical training are determined. These costs are then adjusted to reflect civilian and military pay raises and inflation to arrive at the estimated rates. An asset charge is included to reflect depreciation. For the period beginning April 1, 1994, the rates herein superseded those established by the Director of the Office of Management and Budget on October 1, 1992 (57 CFR 48642). Leon E. Panetta, Director, Office of Management and Budget. Tortiously Liable Rates, Fiscal Year 1994, April 1994 Through September 1994--Inpatient, Outpatient and Other Rates and Charges ------------------------------------------------------------------------ Full reimbursement rate ------------------------------------------------------------------------ I. Per Inpatient Day: A. Burn Center....................................... $2,975 B. Inpatient Other Than Burn Center\1\ Medical Care Services............................ 783 Surgical Care Services........................... 1,082 Obstetrical and Gynecological Care............... 1,020 Pediatric Care................................... 785 Orthopedic Care.................................. 977 Psychiatric Care and Substance Abuse............. 479 Medical Intensive Care and Coronary Care......... 1,703 Surgical Intensive Care.......................... 1,855 Neonatal Intensive Care.......................... 1,087 Organ and Bone Marrow Transplant................. 1,533 Same Day Surgery................................. 426 II. Per Outpatient Visit:\2\ A. Medical Treatment Facilities...................... 101 B. PRIMUS/NAVCARE.................................... \3\61 III. Other Rates and Charges: A. Hyperbaric Services: 1-60 minutes..................................... 177 61-120 minutes................................... 345 121-180 minutes.................................. 512 181-240 minutes.................................. 679 ------------------------------------------------------------------------ (Note: Charges may be prorated based on usage.) ---------------------------------------------------------------------------------------------------------------- Total dispensed Standard Generic (trade) name Strength quantity\4\ cost ---------------------------------------------------------------------------------------------------------------- B. High Cost Medications Requested By External Providers:\3\ 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 btls.......... 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 btls.......... 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 btls.......... 183 Cromolyn soln (nebulizer).............................. .................... 360 amp......... 204 Cyclophosphamide....................................... 25mg................ 360............. 360 Cyclophosphamide....................................... 50mg................ 360............. 681 Cyclosporine........................................... 100mg............... 60.............. 257 Cyclosporine........................................... 100mg/ml sol........ 3 btls.......... 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 btls.......... 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............. 11 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 ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ Cost of Service provided service ------------------------------------------------------------------------ C. High Cost Services Requested By External Providers:\3\ 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 ------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------- Inter- Common National classification procedure ------------------------------------------------- Cosmetic surgery procedure diseases (ICD- terminology Full 9) (CPT)\5\ FY 94 charge\6\ reimbursement ---------------------------------------------------------------------------------------------------------------- D. Elective Cosmetic Surgery Procedures and Rates Mammaplasty.................. 85.50 19325 Surgical Care Services or........ $1,082 85.32 19324 Same Day Surgery................. 426 85.31 19318 ................................. ............. Mastopexy.................... 85.60 19316 Surgical Care Services or........ 1,082 Same Day Surgery................. ............. Facial....................... 86.82 15824 Surgical Care Services or........ 1,082 Rhytidectomy............. 86.22 ........... Same Day Surgery................. 426 Blepharoplasty............... 08.70 15820 Surgical Care Services or........ 1,082 08.44 15821 Same Day Surgery................. 426 .............. 15822 ................................. ............. .............. 15823 ................................. ............. Mentoplasty.................. 76.68 21208 Surgical Care Services or........ 1,082 (Augumentation Reduction) 76.67 21209 Same Day Surgery................. 426 Abdominoplasty............... 86.83 15831 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Lipectomy, suction per 86.83 15876 Surgical Care Services or........ 1,082 region\7\. .............. 15877 Same Day Surgery................. 426 .............. 15878 ................................. ............. .............. 15879 ................................. ............. Rhinoplasty.................. 21.87 30400 Surgical Care Services or........ 1,082 21.86 30410 Same Day Surgery................. 426 Scar revisions beyond CHAMPUS 86.84 1587 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Mandibular or Maxillary 76.41 21194 Surgical Care Services or........ 1,082 Repositioning. Same Day Surgery................. 426 Minor Skin Lesions\8\........ 86.30 1578 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Dermabrasion................. 86.25 15780 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Hair Restoration............. 86.64 15775 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Removing Tatoos.............. 86.25 15780 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Chemical Peel................ 86.24 15790 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Arm/Thigh Dermolipectomy..... 86.83 1583 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 Brow Lift.................... 86.3 15839 Surgical Care Services or........ 1,082 Same Day Surgery................. 426 ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- Inpatient rate Items included ---------------------------------------------------------------------------------------------------------------- E. Immunization.............................. $18. F. Clinical Services by Types of Service/Care Provided: Medical Care Services.................... Internal Medicine, Cardiology, Dermatology, 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 Gynecological Care....... Included Family Practice Obstetrics and 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 Substance Abuse Includes Family Practice Psychiatric Care. Rehabilitation. Medical Intensive Care/Coronary Care..... Self-Explanatory. Surgical Intensive Care.................. Self-Explanatory. Neonatal Intensive....................... Self-Explanatory. Organ and Bone Marrow Transplants........ Self-Explanatory. 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) 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 standard 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 domestic surgery. \6\Cosmetic surgery rates will be charged 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 1-2, page 1-7 entitled Inpatient and Outpatient Rates). 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 mammaplasty 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. [FR Doc. 94-18061 Filed 7-28-94; 8:45 am] BILLING CODE 3110-01-M