[Federal Register Volume 61, Number 217 (Thursday, November 7, 1996)]
[Notices]
[Pages 57654-57659]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-28660]
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DEPARTMENT OF DEFENSE
Office of the Secretary
Medical and Dental Reimbursement Rates for Fiscal Year 1997
Notice is hereby given that the Deputy Chief Financial Officer, in
a memorandum dated September 19, 1996, established the following
reimbursement rates for inpatient and outpatient medical care to be
provided in FY 1997. These rates are effective October 1, 1996.
Inpatient, Outpatient and Other Rates and Charges
I. Inpatient Rates \1\ \2\
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International Interagency
military and other
Per inpatient day education and Federal agency Other
training sponsored
(IMET) patients
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A. Burn Center.................................................. $2,107.00 $3,824.00 $4,086.00
B. Surgical Care Services (Cosmetic Surgery).................... 897.00 1,629.00 1,741.00
C. All Other Inpatient Services (Based on Diagnosis Related
Groups (DRG) Charges \3\)
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1. FY 1997 Direct Care Inpatient Reimbursement Rates
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Other (full/
Adjusted standard amount IMET Interagency 3rd party)
------------------------------------------------------------------------
Large Urban...................... $2,154 $4,141 $4,392
Other Urban/Rural................ 2,275 4,344 4,635
Overseas......................... 2,405 5,207 5,533
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2. Overview
The FY 1997 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 costs
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 outliers. The
published ASAs will be adjusted for area wage differences and indirect
medical education (IME) for the discharging hospital. An example of how
to apply DoD costs to a DRG standardized weight to arrive at DoD costs
is contained in section 1.C.3, below.
3. Example of Adjusted Standardized Amounts for Inpatient Stays
Figure 1 shows an example for a nonteaching hospital in a large
urban area.
a. The cost to be recovered is DoD's cost for medical services
provided in the nonteaching hospital located in a large urban area.
Billings will be at third party rate.
b. DRG 020: Nervous System Infection Except Viral Meningitis. The
RWP for an inlier case is the CHAMPUS weight of 2.9769. (DRG statistics
shown are from FY 1996.)
c. The DoD Adjusted Standardized Amount to be charged is $4,392
(the third party rate as shown in paragraph I.C.1).
d. DoD costs to be recovered at a nonteaching hospital with area
wage index of 1.0 is the RWP factor in item b, above, times the amount
in item c (2.9769 x $4,392).
e. Cost to be recovered is $13,075.
Figure 1.--Third Party Billing Example
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Arithmetic Geometric Short stay Long stay
DRG No. DRG description DRG weight mean LOS mean LOS threshold threshold
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020...................... Nervous System 2,9769 11.2 7.8 1 30
Infection Except
Viral Meningitis.
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Area wage IME
Hospital Location rate index adjustment Group ASA Applied ASA
Nonteaching Hospital......... Large Urban.................. 1.0 1.0 $4,392 $4,392
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Relative weighted product
Patient No. Length of stay Days above --------------------------------------- TPC amount
threshold Inlier \1\ Outlier \2\ Total \3\
1.......................................... 7 days.................................... 0 2.9769 0.0000 2.9769 $13,075
2.......................................... 21 days................................... 0 2.9769 0.0000 2.9769 13,075
[[Page 57655]]
3.......................................... 35 days................................... 5 2.9769 0.8397 3.8166 16,763
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\1\ DRG weight.
\2\ Outlier calculation=44 percent of per diem weight multiplied by the number of outlier days:
=.44 x (DRG Weight/Geometric Mean LOS) x (Patient LOS Long Stay Threshold).
=.44 x (2.9769/7.8) x (35-30).
=.44 x (.38165) x 5 (take out to 5 decimal places).
=.16793 x 5 (take out to 5 decimal places).
=.8397 (take out to 4 decimal places).
\3\ Applied ASA x Total RWP.
II. Outpatients Rates \1\ \2\
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Interagency
International and other
military Federal
MEPRS code \4\ Per visit clinical services education and agency Other
training sponsored
(IMET) patients
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A. Medical Care
----------------------------------------------------------------------------------------------------------------
BAA............................ Internal Medicine..................... $92 $167 $178
BAB............................ Allergy............................... 34 61 66
BAC............................ Cardiology............................ 61 111 119
BAE............................ Diabetes.............................. 57 103 110
BAF............................ Endocrinology......................... 71 130 139
BAG............................ Gastroenterology...................... 89 162 173
BAH............................ Hematology............................ 89 162 173
BAI............................ Hypertension.......................... 60 108 116
BAJ............................ Nephrology............................ 114 207 221
BAK............................ Neurology............................. 86 156 167
BAL............................ Nutrition............................. 24 43 46
BAM............................ Oncology.............................. 81 148 158
BAN............................ Pulmonary Disease..................... 97 175 187
BAO............................ Rheumatology.......................... 73 133 142
BAP............................ Dermatology........................... 54 98 105
BAQ............................ Infectious Disease.................... 76 139 148
BAR............................ Physical Medicine..................... 73 132 141
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B. Surgical Care
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BBA............................ General Surgery....................... 107 193 207
BBB............................ Cardiovascular/Thoracic Surgery....... 92 167 178
BBC............................ Neurosurgery.......................... 108 197 210
BBD............................ Ophthalmology......................... 72 131 140
BBE............................ Organ Transplant...................... 109 199 212
BBF............................ Otolaryngology........................ 83 150 160
BBG............................ Plastic Surgery....................... 87 158 169
BBH............................ Proctology............................ 63 114 122
BBI............................ Urology............................... 93 169 180
BBJ............................ Pediatric Surgery..................... 53 97 103
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C. Obstetrical and Gynecological (OB-GYN)
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BCA............................ Family Planning....................... 59 108 115
BCB............................ Gynecology............................ 67 121 129
BCC............................ Obstetrics............................ 63 114 121
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D. Pediatric Care
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BDA............................ Pediatric............................. 51 93 100
BDB............................ Adolescent............................ 49 89 95
BDC............................ Well Baby............................. 30 54 58
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E. Orthopaedic Care
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BEA............................ Orthopaedic........................... 74 135 144
BEB............................ Cast Clinic........................... 34 63 67
BEC............................ Hand Surgery.......................... 37 67 72
BEE............................ Orthopaedic Appliance................. 53 95 102
BEF............................ Podiatry.............................. 44 80 86
[[Page 57656]]
BEZ............................ Chiropractic Clinic................... 24 44 47
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F. Psychiatric and/or Mental Health Care
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BFA............................ Psychiatry............................ 79 144 154
BFB............................ Psychology............................ 75 137 146
BFC............................ Child Guidance........................ 46 83 89
BFD............................ Mental Health......................... 71 129 138
BFE............................ Social Work........................... 60 109 117
BFF............................ Substance Abuse Rehabilitation........ 60 110 117
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G. Primary Medical Care
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BGA............................ Family Practice....................... 58 106 113
BHA............................ Primary Care.......................... 56 102 109
BHB............................ Medical Examination................... 50 91 97
BHC............................ Optometry............................. 37 68 73
BHD............................ Audiology Clinic...................... 27 48 52
BHE............................ Speech Pathology...................... 60 108 116
BHF............................ Community Health...................... 39 70 75
BHG............................ Occupational Health................... 51 92 98
BHI............................ Immediate Care Clinic................. 75 137 146
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H. Emergency Medical Care
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BIA............................ Emergency Care Clinic................. 91 164 176
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I. Flight Medicine Clinic
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BJA............................ Flight Medicine....................... 85 154 164
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J. Underseas Medicine Care
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BKA............................ Underseas Medicine Clinic............. 26 46 50
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K. Rehabilitative Services
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BLA............................ Physical Therapy...................... 24 44 47
BLB............................ Occupational Therapy.................. 32 58 62
BLC............................ Neuromuscularskeletal Screening....... 20 37 39
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L. Ambulatory Procedure Visit
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413 746 797
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III. Other Rates and Charges
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Interagency
International and other
military Federal
MEPRS code \4\ Per visit clinical service education and agency Other
training sponsored
(IMET) patients
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FBI............................ A. Immunizations...................... $8.00 $15.00 $16.00
DGC............................ B. Hyperbaric Services \5\ (per hour). 110.00 201.00 214.00
C. Family Member Rate (formerly 9.90
Military Dependents Rate).
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D. Reimbursement Rates for High Cost Drugs Requested by External
Providers \6\
The FY 1997 high cost drug reimbursement rates are for
prescriptions requested by external providers and obtained at the
military treatment facility. The high cost drug reimbursement rates are
too numerous to include in this notice. A complete listing of these
rates is available on request from OASD (Health Affairs), LCDR Pat
Kelly, (703) 681-8910.
[[Page 57657]]
E. Reimbursement Rates for High Cost Services Requested by External
Providers \7\
The FY 1997 high cost services requested by external providers and
obtained at the military treatment facility are too numerous to include
in this notice. A complete listing of these rates is available on
request from OASD (Health Affairs), LCDR Pat Kelly, (703) 681-8910.
F. Elective Cosmetic Surgery Procedures and Rates
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International Current
classification procedural Amount of
Cosmetic surgery procedure diseases (ICD- terminology FY 97 charge \9\ charge
9) (CPT) \8\
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Mammaplasty.................................... 85.50 19325 Surgical Care Services or Ambulatory Procedure Visit......... (a)
85.32 19324 (b)
85.31 19318
Mastopexy...................................... 85.60 19316 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Facial......................................... 86.82 15824 Surgical Care Services or Ambulatory Procedure Visit......... (a)
Rhytidectomy................................... 86.22 (b)
Blepharoplasty................................. 08.70 15820 Surgical Care Services or Ambulatory Procedure Visit......... (a)
08.44 15821 (b)
15822
15823
Mentoplasty (Augmentation/Reduction)........... 76.68 21208 Surgical Care Services or Ambulatory Procedure Visit......... (a)
76.67 21209 (b)
Abdominoplasty................................. 86.83 15831 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Lipectomy, Suction per Region \10\............. 86.83 15876 Surgical Care Services or Ambulatory Procedure Visit......... (a)
15877 (b)
15878
15879
Rhinoplasty.................................... 21.87 30400 Surgical Care Services or Ambulatory Procedure Visit......... (a)
21.86 30410 (b)
Scar Revisions beyond CHAMPUS.................. 86.84 1578__ Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Mandibular or Maxillary Repositioning.......... 76.41 21194 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Minor Skin Lesions \11\........................ 86.30 1578__ Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Dermabrasion................................... 86.25 15780 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Hair Restoration............................... 86.64 15775 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Removing Tattoos............................... 86.25 15780 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Chemical Peel.................................. 86.24 15790 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Arm/Thigh Dermolipectomy....................... 86.83 1583__ Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
Brow Lift...................................... 86.3 15839 Surgical Care Services or Ambulatory Procedure Visit......... (a)
(b)
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G. Dental Rate
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Interagency
International and other
military Federal
MEPRS code \4\ Per visit clinical service \12\ education and agency Other
training sponsored
(IMET) patients
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CA............................. Dental Services (CTV 1)............... $9.00 $25.00 $26.00
CA............................. Dental Services (CTV 2)............... 7.00 20.00 21.00
CB............................. Dental Prosthetics Laboratory (CLV)... 2.00 6.00 6.00
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H. Ambulance Rate \13\
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Interagency
International & other
Military Federal
MEPRS code \4\ Per visit clinical service Education and agency Other
Training sponsored
(IMET) patients
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FEA............................ Ambulance Service..................... $57.00 $103.00 $110.00
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[[Page 57658]]
I. High Cost Laboratory and Radiology Service \7\
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Interagency
International & other
Military Federal
MEPRS code \4\ Per visit clinical service Education and agency Other
Training sponsored
(IMET) patients
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High cost laboratory CPT-4 multiplier. $6.00 $10.00 $11.00
High cost radiology CPT-4 multiplier.. 20.00 36.00 38.00
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J. AirEvac Rate\14\
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International Interagency and
Per visit clinical Military Education other Federal
MEPRS code\4\ service and Training agency sponsored Other
(IMET) patients
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AirEvac Services $89.00 $162.00 $173.00
(Ambulatory).
AirEvac Services 265.00 481.00 513.00
(Litter).
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Notes on Cosmetic Surgery Charges
a Charges for inpatient Surgical Care Services are
contained in Section I.B. (See Notes 9 through 11 on reimbursable
rates for further details.)
b Charges for Ambulatory Procedure Visits (formerly Same
Day Surgery) are contained in Section II.L. (See Notes 9 through 11
on reimbursable rates for further details.)
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 96 percent hospital and 4 percent
professional fee. The outpatient per visit percentages are 58
percent hospital, 30 percent ancillary and 12 percent professional.
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 The cost per DRG (Diagnosis Related Groups) 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 will be comparable
to procedures utilized by 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.
4 The Medical Expense and Performance Reporting System
(MEPRS) code is a three digit code which defines the summary account
and the subaccount within a functional category in the DoD medical
system. An example of this hierarchical arrangement is as follows:
------------------------------------------------------------------------
Outpatient care (functional category) MEPRS code
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Medical Care (Summary Account)............ BA
Internal Medicine (Subaccount)............ BAA
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MEPRS codes are used to ensure that consistent expense and operating
performance data is reported in the DoD military medical system.
5 Hyperbaric services are to be charged based on full hours
and 15 minute increments of service. Providers should calculate the
charges based on the number of hours (or fraction thereof) of
service. Fractions of hours should be rounded to the next 15 minute
increment (e.g. 31 minutes becomes 45 minutes).
6 High cost prescription services requested by external
providers (Physicians, Dentists, etc.) are relevant to the Third
Party Collection Program. Third party payers (such as insurance
companies) shall be billed for high cost prescriptions in those
instances in which beneficiaries who have medical insurance, seen by
providers external to a Military Medical Treatment Facility (MTF),
obtain the prescribed medication from an MTF. Eligible beneficiaries
(family members or retirees with medical insurance) are not
personally liable 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 come to the MTF for
prescription services. A bill will be produced if the total
prescription costs in a day (defined as 0001 hours to 2400 hours)
exceeds $25.00 when bundled together. Bundling refers to the
accumulation of a patient's bills during the previously defined 24
hour period. The standard cost of high cost medications includes the
cost of the drugs plus a dispensing fee, per prescription. The
prescription cost is calculated by multiplying the number of units
(tablets, capsules, etc.) times the unit cost and adding a $5.00
dispensing fee per prescription.
\7\ Charges for high cost ancillary services requested by
external providers (Physicians, Dentists, etc.) are 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 beneficiaries who have medical insurance, are
seen by providers external to an MTF, and obtain the prescribed
service from an MTF. Laboratory and Radiology procedure costs are
calculated using the CPT-4 weight multiplied by either the high cost
laboratory or radiology multiplier (Section III.I). 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 come to the MTF for high cost
services. A bill will be produced if the total ancillary services
costs in a day (defined as 0001 hours to 2400 hours) exceed $25.00
when bundled together. Bundling refers to the accumulation of a
patient's bill during the previously defined 24 hour period.
\8\ The attending physician is to complete the Physicians'
Current Procedural Terminology code to indicate the appropriate
procedure followed during cosmetic surgery. The appropriate rate
will be applied depending on the admission type of the patient,
e.g., ambulatory procedure visit or inpatient surgical care
services.
\9\ Family members of active duty personnel, retirees and their
family members, and survivors will be charged cosmetic surgery
rates. The patient shall be charged the rate as specified in the FY
1997 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 Surgical Care Services in
Section I.B., or Ambulatory Procedure Visits as contained in Section
II.L of this attachment. The patient will be responsible for both
the cost of the implant(s) in addition to the prescribed cosmetic
surgery rates.
[[Page 57659]]
Note: The implants and procedures used for the augmentation
mammaplasty are in compliance with Federal Drug Administration
guidelines.
\10\ Each regional lipectomy will carry a separate charge.
Regions include head and neck, abdomen, flanks, and hips.
\11\ 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.
\12\ Dental services are based on a Composite Time Value (CTV).
Charges should be calculated based on the time value of the
procedure times the CTV rate. The first CTV (1.0 value) shall be
calculated using the CTV 1 rate. Any subsequent CTVs and portions
thereof shall be calculated using the CTV 2 rate. The Composite Lab
Value (CLV) should be used to calculate charges for dental
appliances and prostheses.
\13\ Ambulance charges are based on full hours and 15 minute
increments of service. Providers should calculate the charges based
on the number of hours (or fraction thereof) that the ambulance is
logged out on a patient run. Fractions of hours should be rounded to
the next 15 minute increment (e.g. 31 minutes becomes 45 minutes).
\14\ Air in-flight medical care reimbursement charges are
determined by the status of the patient (Litter or Ambulatory) and
are per patient.
Dated: November 4, 1996.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 96-28660 Filed 11-6-96, 8:45 am]
BILLING CODE 5000-04-M