Federal Register: October 31, 2003 (Volume 68, Number 211)
DOCID: FR Doc 03-27360
OFFICE OF MANAGEMENT AND BUDGET
Management and Budget Office
NOTICE: NOTICES
SUBJECT CATEGORY:
Cost of Hospital and Medical Care Treatment Furnished by the United States; Certain Rates Regarding Recovery From Tortiously Liable Third Persons
DOCUMENT SUMMARY:
By virtue of the authority vested in the President by Section 2(a) of Pub. L. 87693 (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 Federal Register 10737), the two 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 and will remain in effect until further notice. The rates for the Department of Veterans Affairs and the Indian Health Service in the Department of Health and Human Services that were published in the Federal Register on October 31, 2000 and December 26, 2001, respectively, remain in effect until further notice. In addition, the inpatient rates for the Department of Defense published in on December 9, 2002 remain in effect until further notice. The rates are as follows:
1. Department of Defense
The Fiscal Year (FY) and Calendar Year (CY) 2003 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 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Maximum Allowable Charges (CMAC, section II), Dental (section III. F), Pharmacy (section III. D), and Durable Medical Equipment/Durable Medical Supplies (DME/DMS) (section III. K) are not included in this package. Those rates are available from the TRICARE Management Activity (TMA) Uniform Business Office (UBO) Web site: http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
The outpatient rates in this package will have an effective date of May 1, 2003. The inpatient medical rates in this package, republished in this package, are from the December 9, 2002 package and are referenced above on the UBO Web site; these became effective October 1, 2002.
A government billing calculation factor (percentage discount) for
billing outpatient International Military Education and Training (IMET)
(58.57% of full rate), and Interagency and Other Federal Agency
Sponsored Patients (IAR) rate (93.14% of full rate), will be applied to
the line item charges calculated for outpatient medical and ancillary services using CMAC or anesthesia charges.
Inpatient, Outpatient, and Other Rates and Charges
I. Inpatient Rates
A. All Inpatient Services
(Based on Diagnosis Related Groups (DRG) \1\ \2\)
1. Average FY 2003 Direct Care Inpatient Reimbursement Rates
Interagency
International and other Other
military federal (full/
Adjusted standard amount (ASA) education & agency third
training sponsored party)
(IMET) patients
Large Urban..................... $3,521.00 $6,434.00 $6,748.00
Other Urban/Rural............... 4,316.00 7,191.00 7,575.00
Overseas........................ 4,443.00 9,879.00 10,344.00 2. Overview
The FY 2003 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.A.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 CHAMPUS pursuant to 32 CFR
199.14(a)(1), including adjustments for length of stay (LOS) outliers.
Each military treatment facility (MTF) providing inpatient care has a
separate ASA rate. The MTFspecific 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 MTFspecific ASA
rate submitted on the claim is the rate that payers will use for reimbursement purposes. An example of
[[Page 62105]]
how to apply a specific military treatment facility's ASA rate to a DRG
standardized weight to arrive at the costs to be recovered is contained in paragraph I.A.3., below.
3. Example of Adjusted Standardized Amounts for Inpatient Stays
Figure 1 shows examples for a nonteaching hospital (Reynolds Army Community Hospital) in an Other Urban/Rural area.
a. The cost to be recovered is the MTF'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 2.1159. (DRG statistics shown are from FY 2002.)
c. The FY 2003 MTFapplied ASA rate is $7,152.00 (Reynolds Army Community Hospital's third party rate as shown in Attachment 1).
d. The MTF cost to be recovered is the RWP factor (2.1159) in
subparagraph 3.b., above, multiplied by the amount ($7,152.00) in subparagraph 3.c., above.
e. Cost to be recovered is $15,134.00.
Figure 1.Third Party Billing Examples
Arithmetic Geometric Short stay Long stay
DRG No. DRG description DRG weight mean LOS mean LOS threshold threshold
020................... Nervous System 2.1159 7.6 5.5 1 29 Infection Except Viral
Meningitis.
Area wage IME MTFapplied
Hospital Location rate index adjustment Group ASA ASA
Reynolds Army Community Hospital.... Other Urban/Rural..... .8251 1.0 $7,575.00 $7,152.00
Relative weighted product
Patient Length of stay Days above TPC amount
threshold Inlier * Outlier ** Total ***
** Outlier calculation = 33 percent of per diem weight x number of outlier days.
=.33 (DRG Weight/Geometric Mean LOS) x (Patient LOSLong Stay Threshold). =.33 (2.1159/5.5) x (3529).
=.33 (.38471) x 6 (extend to five decimal places).
=.12695 x 6 (extend to five decimal places).
=.7617 (extend to four decimal places).
*** MTFApplied ASA x Total RWP.
II. Outpatient Rates \2\ \3\ \4\
A. CMAC Rates. The CHAMPUS Maximum Allowable Charge (CMAC) rates,
established under 32 CFR 199.14(h), are used for determining the
appropriate charge for services in an itemized format, based on
Healthcare Common Procedure Coding System (HCPCS) methodology. The CMAC
rates are available on the TMA UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm. The
CMAC rate tables contain the rates for radiology, laboratory, clinic
procedures/services, and Evaluation and Management (E/M) Current Procedural Terminology (CPT) codes.
CMAC is organized by 90 distinct ``localities,'' which account for differences in geographic regions based on demographics, cost of living, and population. Each MTF Defense Military Information System identification (DMIS ID) will map to a locality code to obtain the correct rates. For the complete DMIS ID locality table please refer to the DMIS ID Web site at http://www.dmisid.com/cgidmis/default.
In each locality, there are three subtables of rates: CMAC, Component, and NonCMAC. The CMAC rate table determines the payment for individual professional services and procedures identified CPT and HCPCS codes. The Component rate table is based on component rates comprising professional, technical and global rates. The NonCMAC rate table captures pricing for procedure codes at the local or state level. Each state/locality does not have the same set of prevailing rates. When rates are pulled from the NonCMAC table, the prevailing local fee is used in all cases.
Within the CMAC tables, the rates are based not only on HCPCS but on a ``Provider Class'' based on medical specialty of the provider. Each provider is mapped to a provider class to calculate the correct rate.
B. Per ClinicVisit. With implementation of OIB, an allinclusive rate per clinic visit will no longer be charged. Instead, charges will be based on services provided and will be itemized.
C. Ambulatory Procedure Visit (APV)Per Visit \5\. APV charges are based on the CPT codes of the procedures performed. An itemized bill will be produced for the charges associated with the APV including ancillaries and anesthesia as applicable.
III. Other Rates and Charges
A. Immunization The charge for immunizations, allergen extracts, allergic condition tests, and the administration of certain medications when these services are provided in a separate immunization or shot clinic, are based on CMAC rates in cases in which such rates are available. In cases in which such rates are not available, rates will be based on the average full cost of these services, exclusive of any costs considered for purposes of any outpatient visit. A separate charge shall be made for each immunization, injection or medication administered. If there is no CMAC rate available for an immunization or injection then the flat rate of $34.00 will be billed.
B. Subsistence Rate \6\. The standard and discount rates for subsistence are available from the DoD Comptrollers Web site, Tab G: http://www.dod.mil/comptroller/ratesindex2003.html.
C. Family Member Rate $12.72 (with exception of spouses and other [[Page 62106]]
dependents of enlisted personnel in pay grades E1 through E4, who are
charged the discount meal rateSee Comptrollers Web site, Tab G:
http://www.dod.mil/comptroller/ratesindex2003.html.
D. Pharmacy \7\. All medications, both internal and external, are billable. The rates for pharmacy are based on the average full cost of these drugs. These rates will be updated quarterly. These rates in this table are based on National Drug Code (NDC) codes. This rate table may be found on the TMA UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
E. Ancillary Services. Per Procedure \8\. All Laboratory and
Radiology procedures will be billed per CMAC Rates, including those associated with a clinic visit.
F. Dental RatePer Procedure \9\.
Interagency
International and other
military Federal Other (full/
CDT/CPT Clinical service education and agency third
training sponsored party)
(IMET) patients
Dental Services ADA code weight $26.00 $60.00 $63.00 multiplier.
G. Ambulance RatePer Hour \10\.
Interagency
International and other
military Federal Other (full/
CDT/CPT Clinical service education and agency third
training sponsored party)
(IMET) patients
A0999............................ Ambulance........................... $102.00 $140.00 $147.00
H. AirEvac RatePer Trip (24hour period) 11. International Interagency & military other Federal Clinical Service education & agency Other (full/ training sponsored third party) (IMET) patients AirEvac ServicesAmbulatory.................................... $361.00 $494.00 $518.00 AirEvac ServicesLitter........................................ 1,047.00 1,435.00 1,503.00
I. Observation RatePer Hour 12. Under OIB, observation services will be billed according to applicable CPT codes.
J. Anesthesia The flat rate for anesthesia services is based on an average DoD cost of service in all MTFs. The range of HCPCS codes for anesthesia is 0010001999. The flat rate for anesthesia will be $174.00.
K. Durable Medical Equipment/Durable Medical Supplies (DME/DMS)
Durable Medical Equipment (DME) and Durable Medical Supplies (DMS) are
based on the Medicare Fee Schedule floor rate. The HCPCS codes
contained in this table are for A4212A7509, E0100E2101, K0001K0551,
L0100L8670, and V2020V2780. This rate table may be found on the TMA
UBO Web Site at http://www.tricare.osd.mil/ebc/rm_ home/ubo documentsratestables.cfm.
IV. Elective Cosmetic Surgery Procedures and Rates 13/
Current procedural Amount of
Cosmetic surgery procedure terminology (CPT)e FY 2003 charge charge
Abdominoplasty....................... 15831........................ Inpatient Charge per DRG or (a b c)
CPT.
Blepharoplasty....................... 15820, 15821, 15822, 15823... Inpatient Charge per DRG or (a b c)
CPT.
Botox Injection for rhytids.......... J0585........................ Inpatient Charge per DRG or (a b c)
CPT.
Brachioplasty........................ 15836........................ Inpatient Charge per DRG or (a b c)
CPT.
Brow Lift............................ 15824, 15839................. Inpatient Charge per DRG or (a b c)
CPT.
Buttock Lift......................... 15835........................ Inpatient Charge per DRG or (a b c)
CPT.
Canthopexy........................... 21282, 67950................. Inpatient Charge per DRG or (a b c)
CPT.
Cervicoplasty........................ 15819........................ Inpatient Charge per DRG or (a b c)
CPT.
Chemical Peel........................ 15788, 15789, 15792, 15793... Inpatient Charge per DRG or (a b c)
CPT.
Collagen Injection, subcutaneous..... 11950, 11951, 11952, 11954... Inpatient Charge per DRG or (a b c)
CPT.
Dermabrasion......................... 15780, 15781, 15782, 15783... Inpatient Charge per DRG or (a b c)
CPT.
Arm/Thigh Dermolipectomy............. 15836, 15832................. Inpatient Charge per DRG or (a b c)
CPT. [[Page 62107]]
Excision/destruction of minor benign 11400, 11401, 11402, 11403, Inpatient Charge per DRG or (a b c)
skin lesions. 11404, 11406, 11420, 11421, CPT.
11422, 11423, 11424, 11426,
11440, 11441, 11442, 11443,
11444, 11446, 17000, 17003,
17004, 17106, 17107, 17108,
17110, 17111, 17250.
Facial Rhytidectomy.................. 15824, 15825, 15826, 15828, Inpatient Charge per DRG or (a b c)
15829. CPT.
Genioplasty.......................... 21120, 21121................. Inpatient Charge per DRG or (a b c)
CPT.
Hair Restoration..................... 15775, 15776................. Inpatient Charge per DRG or (a b c)
CPT.
Hip Lift............................. 15834........................ Inpatient Charge per DRG or (a b c)
CPT.
Laser Resurfacing.................... 17999........................ Inpatient Charge per DRG or (a)
CPT.
Lipectomy Suction per region......... 15876, 15877, 15878, 15879... Inpatient Charge per DRG or (a b c f)
CPT.
Malar Augmentation................... 21270........................ Inpatient Charge per DRG or (a b c)
CPT.
Mammaplastyaugmentation............ 19318, 19324, 19325,......... Inpatient Charge per DRG or (a b)
CPT.
Mandibular or Maxillary Repositioning 21194........................ Inpatient Charge per DRG or (a b c)
CPT.
Mastopexy............................ 19316........................ Inpatient Charge per DRG or (a b c)
CPT.
Mentoplasty (Augmentation/Reduction). 21208, 21209................. Inpatient Charge per DRG or (a b c)
CPT.
Otoplasty............................ 69300........................ Inpatient Charge per DRG or (a b c)
CPT. Refractive surgery (see the following
two procedures):
Radial Keratotomy.................... 65771........................ CPT......................... (b c d)
Other Procedure (if applies to 66999........................ CPT......................... (b c d) laser or other refractive
surgery).
Rhinoplasty.......................... 30400, 30410, 30430, 30435, Inpatient Charge per DRG or (a b c)
30450, 30460, 30462. CPT.
Scar Revisions beyond CHAMPUS........ 13120, 13121, 13122, 13131, Inpatient Charge per DRG or (a b c)
13132, 13133, 13150, 13152, CPT. 13153.
Sclerotherapy........................ 36468, 36469, 36470, 36471, Inpatient Charge per DRG or (a b c)
15780, 15781, 15782, 15783, CPT. 15786.
Tattoo Removal....................... 15780, 15783, 17999.......... Inpatient Charge per DRG or (\a\ \b\
CPT. \c\)
Thigh Lift........................... 15832........................ Inpatient Charge per DRG or (\a\ \b\
CPT. \c\)
Vein Stripping....................... 37720, 37730, 37735.......... Inpatient Charge per DRG or (\a\ \b\
CPT. \c\) Notes on Cosmetic Surgery Charges:
\a\ Charges for Inpatient surgical care services are based on the cost per DRG.
\b\ Charges for outpatient surgical care services are based on the cost per CPT code.
\c\ All required DoD guidelines and instructions for APVs must be followed. An ambulatory procedure visit is
defined in DoD Instruction 6025.8, ``Ambulatory Procedure Visit (APV),'' dated September 23, 1996, as
immediate (day of procedure) preprocedure and immediate postprocedure 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 MTFestablished APU associated with the referring clinic.
\d\ Refer to Office of the Assistant Secretary of Defense (Health Affairs) policy on Vision Correction Via Laser
Surgery For NonActive Duty Beneficiaries, April 7, 2000, for further guidance on billing for these services.
The policy can be downloaded from: http://www.ha.osd.mil/policies/2000/00_003.pdf.
\e\ The attending physician is to document and record the appropriate DRG/CPT code to indicate the procedure
followed during cosmetic surgery. It is up to the physician to decide whether or not the services are considered medically necessary or elective.
\f\ Each regional lipectomy shall carry a separate charge. Regions include head and neck, abdomen, flanks, and hips.
Notes on Reimbursable Rates
\1\ 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 ASA per
RWP for use in the direct care system is comparable to procedures
used by the Centers for Medicare and Medicaid Services (CMS) and
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 above. The ASA rate used in these
cases, based on the absence of an 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.A.1.). The UBO must receive documentation of care provided in order to produce a bill.
\2\ Percentages can be applied when preparing bills for
inpatient services. Pursuant to the provisions of 10 U.S.C. 1095,
the inpatient Diagnosis Related Groups percentages are 96 % hospital
and 4% professional charges. When preparing bills for outpatient
services, professional fees are based on the E/M charges, the
hospital fees are based on the charges for ancillary services, pharmacy and supplies.
\3\ 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.
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
\4\ The following chart of MEPRS work centers are DoD approved
for outpatient itemized billing. Claims can be generated for
encounters, ancillaries, pharmacy, DME/DMS, etc. from these workcenters.
MEPRS code Clinical service BAA Internal Medicine.
[[Page 62108]]
BAB Allergy.
BAC Cardiology.
BAE Diabetic.
BAF Endocrinology (Metabolism). BAG Gastroenterology.
BAH Hematology.
BAI Hypertension.
BAJ Nephrology.
BAK Neurology.
BAL Outpatient Nutrition.
BAM Oncology.
BAN Pulmonary Disease.
BAO Rheumatology.
BAP Dermatology.
BAQ Infectious Disease.
BAR Physical Medicine.
BAS Radiation Therapy.
BAT Bone Marrow Transplant. BAU Genetic.
BAV Hyperbaric.
BBA General Surgery.
BBB Cardiovascular and Thoracic Surgery. BBC Neurosurgery.
BBD Ophthalmology.
BBE Organ Transplant.
BBF Otolaryngology.
BBG Plastic Surgery.
BBH Proctology.
BBI Urology.
BBJ Pediatric Surgery.
BBK Peripheral Vascular Surgery. BBL Pain Management.
BBM Vascular and Interventional Radiology.
BCA Family Planning.
BCB Gynecology.
BCC Obstetrics.
BCD Breast Cancer Clinic.
BDA Pediatric.
BDB Adolescent.
BDC Well Baby.
BEA Orthopedic.
BEB Cast.
BEC Hand Surgery.
BEE Orthotic Laboratory.
BEF Podiatry.
BEZ Chiropractic.
BFA Psychiatry.
BFB Psychology.
BFC Child Guidance.
BFD Mental Health.
BFE Social Work.
BFF Substance Abuse.
BGA Family Practice.
BHA Primary Care.
BHC Optometry.
BHD Audiology.
BHE Speech Pathology.
BHF Community Health.
BHG Occupational Health.
BHH TRICARE Outpatient.
BHI Immediate Care.
BIA Emergency Medical.
BKA Underseas Medicine.
BLA Physical Therapy.
BLB Occupational Therapy.
MEPRS code Other billable services DAA Pharmacy.
DBA Clinical Pathology.
DBB Anatomical Pathology.
DBD Cytogenetic Laboratory.
DBE Molecular Genetic Laboratory.
DBF Biochemical Genetic Laboratory. DCA Diagnostic Radiology.
FBI Immunizations.
FBN Hearing Conservation (MSA Billing Only).
FC Pharmacy, Laboratory and Radiology
(External Civilian Ancillary and
Support to other Military and
Federal), except in cases where
there is a specific VA/DoD MOU. FEA Ambulance.
5 Ambulatory procedure visit is defined in DoD
Instruction 6025.8, ``Ambulatory Procedure Visit (APV),'' dated
September 23, 1996, as immediate (day of procedure) preprocedure
and immediate postprocedure 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.
6 Subsistence is billed under the Medical Services
Account (MSA) Program only. The MSA office shall collect subsistence
charges from all persons, including inpatients and transient
patients not entitled to food service at Government expense. Please
refer to DoD 6010.15M, Military Treatment Facility UBO Manual,
April 1997, and the DoD 7000.14R, ``Department of Defense Financial
Management Regulation,'' Volume 12, Chapter 19 for guidance on the use of these rates.
7 Third party payers (such as insurance companies)
shall be billed for prescription services when beneficiaries who
have medical insurance obtain medications from MTFs that are
prescribed by providers both internal and 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 includes the DoDwide
average cost of the drug, calculated by lowest cost for the generic
drugs with the same dosage and strength. 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 TMA's UBO Web
site, http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
8 Charges for ancillary services requested by an
internal (associated with a clinic visit) or 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.
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 not seen by an outside provider and only come to the MTF for ancillary services.
9 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 $9.45 ($63 x .15 = $9.45).
The list of CY 2003 ADA codes and weights for dental services is
too large to include in this document. This rate table may be found
on the TMA's UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
10 Ambulance charges shall be based on hours of
service in 15minute increments. The rates listed in section III.G.
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 15minute increment (e.g., 31 minutes shall be charged as 45 minutes).
11 Air inflight medical care reimbursement charges
are determined by the status of the patient (ambulatory or litter)
and are per patient during a 24hour 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.
12 Observation Services are billed based on
applicable CPTs. 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.
13 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 IV. The patient shall be charged
the rate as specified in the CY 2003 reimbursable rates. The charges for elective
[[Page 62109]]
cosmetic surgery are at the full reimbursement rate (designated as
the ``Other'' rate) for inpatient care services based on the cost
per DRG or CPT. 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.)
Attachment 1.FY 2003 Adjusted Standardized Amounts (ASA) by Military Treatment Facility
DMIS ID MTF name Serv Full rate IAR rate IMET rate TPC rate
0003............... Lyster AHFt. Rucker. A $7,032 $6,676 $4,007 $7,032
0005............... Bassett ACHFt. A 7,794 7,399 4,441 7,794 Wainwright.
0006............... 3 Med GrpElmendorf F 7,624 7,237 4,344 7,624 AFB.
0009............... 56th Med GrpLuke AFB F 6,734 6,421 3,514 6,734
0014............... 60th Med GrpTravis F 10,529 9,995 6,000 10,529 AFB.
0024............... NH Camp Pendleton..... N 8,189 7,808 4,274 8,189
0028............... NH Lemoore............ N 7,554 7,171 4,304 7,554
0029............... NMC San Diego......... N 10,268 9,790 5,359 10,268
0030............... NH Twentynine Palms... N 6,820 6,502 3,559 6,820
0032............... Evans ACHFt. Carson. A 7,564 7,181 4,310 7,564
0033............... 10th Med GrpUSAF F 7,574 7,190 4,316 7,574 Academy.
0035............... NH Groton............. N 7,575 7,191 4,316 7,575
0037............... Walter Reed AMC A 10,415 9,930 5,435 10,415 Washington DC.
0038............... NH Pensacola.......... N 9,119 8,656 5,196 9,119
0039............... NH Jacksonville....... N 8,580 8,180 4,477 8,580
0042............... 96th Med GrpEglin F 9,580 9,095 5,459 9,580 AFB.
0045............... 6th Med GrpMacDill F 6,748 6,434 3,521 6,748 AFB.
0047............... Eisenhower AMCFt. A 9,312 8,839 5,306 9,312 Gordon.
0048............... Martin ACHFt. A 8,315 7,893 4,738 8,315 Benning.
0049............... Winn ACHFt. Stewart. A 7,564 7,180 4,310 7,564
0052............... Tripler AMCFt. A 10,248 9,728 5,839 10,248 Shafter.
0053............... 366th Med GrpMtn F 7,560 7,176 4,308 7,560 Home AFB.
0055............... 375th Med GrpScott F 8,671 8,268 4,525 8,671 AFB.
0056............... NH Great Lakes........ N 6,802 6,486 3,550 6,802
0060............... Blanchfield ACHFt. A 7,025 6,669 4,003 7,025 Campbell.
0061............... Ireland ACHFt. Knox. A 6,620 6,311 3,454 6,620
0064............... BayneJones ACHFt. A 6,987 6,633 3,981 6,987 Polk.
0066............... 89th Med GrpAndrews F 8,944 8,527 4,667 8,944 AFB.
0067............... NNMC Bethesda......... N 10,397 9,913 5,426 10,397
0073............... 81st Med GrpKeesler F 10,103 9,591 5,757 10,103 AFB.
0075............... Wood ACHFt. Leonard A 7,179 6,815 4,091 7,179 Wood.
0078............... 55th Med GrpOffutt F 9,972 9,466 5,682 9,972 AFB.
0079............... 99th Med GrpNellis F 6,763 6,448 3,529 6,763 AFB.
0086............... Keller ACHWest Point A 8,234 7,816 4,692 8,234
0089............... Womack AMCFt. Bragg. A 8,079 7,669 4,604 8,079
0091............... NH Camp LeJeune....... N 7,352 6,980 4,190 7,352
Beginning May 1, 2003, the rates prescribed herein superceded those
established by the Director of the Office of Management and Budget, December 9, 2002 (FR Doc. 0231024). 6
Joshua B. Bolten,
Director, Office of Management and Budget.
[FR Doc. 0327360 Filed 103003; 8:45 am]
BILLING CODE 311001P
SUMMARY:
Hospital and medical care treatment furnished by United States; costs, rates regarding recovery from tortiously liable third persons (Circular A-25),
DOCUMENT BODY 2:
By virtue of the authority vested in the President by Section 2(a) of Pub. L. 87693 (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 Federal Register 10737), the two 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 and will remain in effect until further notice. The rates for the Department of Veterans Affairs and the Indian Health Service in the Department of Health and Human Services that were published in the Federal Register on October 31, 2000 and December 26, 2001, respectively, remain in effect until further notice. In addition, the inpatient rates for the Department of Defense published in on December 9, 2002 remain in effect until further notice. The rates are as follows:
1. Department of Defense
The Fiscal Year (FY) and Calendar Year (CY) 2003 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 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Maximum Allowable Charges (CMAC, section II), Dental (section III. F), Pharmacy (section III. D), and Durable Medical Equipment/Durable Medical Supplies (DME/DMS) (section III. K) are not included in this package. Those rates are available from the TRICARE Management Activity (TMA) Uniform Business Office (UBO) Web site: http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
The outpatient rates in this package will have an effective date of May 1, 2003. The inpatient medical rates in this package, republished in this package, are from the December 9, 2002 package and are referenced above on the UBO Web site; these became effective October 1, 2002.
A government billing calculation factor (percentage discount) for
billing outpatient International Military Education and Training (IMET)
(58.57% of full rate), and Interagency and Other Federal Agency
Sponsored Patients (IAR) rate (93.14% of full rate), will be applied to
the line item charges calculated for outpatient medical and ancillary services using CMAC or anesthesia charges.
Inpatient, Outpatient, and Other Rates and Charges
I. Inpatient Rates
A. All Inpatient Services
(Based on Diagnosis Related Groups (DRG) \1\ \2\)
1. Average FY 2003 Direct Care Inpatient Reimbursement Rates
Interagency
International and other Other
military federal (full/
Adjusted standard amount (ASA) education & agency third
training sponsored party)
(IMET) patients
Large Urban..................... $3,521.00 $6,434.00 $6,748.00
Other Urban/Rural............... 4,316.00 7,191.00 7,575.00
Overseas........................ 4,443.00 9,879.00 10,344.00 2. Overview
The FY 2003 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.A.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 CHAMPUS pursuant to 32 CFR
199.14(a)(1), including adjustments for length of stay (LOS) outliers.
Each military treatment facility (MTF) providing inpatient care has a
separate ASA rate. The MTFspecific 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 MTFspecific ASA
rate submitted on the claim is the rate that payers will use for reimbursement purposes. An example of
[[Page 62105]]
how to apply a specific military treatment facility's ASA rate to a DRG
standardized weight to arrive at the costs to be recovered is contained in paragraph I.A.3., below.
3. Example of Adjusted Standardized Amounts for Inpatient Stays
Figure 1 shows examples for a nonteaching hospital (Reynolds Army Community Hospital) in an Other Urban/Rural area.
a. The cost to be recovered is the MTF'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 2.1159. (DRG statistics shown are from FY 2002.)
c. The FY 2003 MTFapplied ASA rate is $7,152.00 (Reynolds Army Community Hospital's third party rate as shown in Attachment 1).
d. The MTF cost to be recovered is the RWP factor (2.1159) in
subparagraph 3.b., above, multiplied by the amount ($7,152.00) in subparagraph 3.c., above.
e. Cost to be recovered is $15,134.00.
Figure 1.Third Party Billing Examples
Arithmetic Geometric Short stay Long stay
DRG No. DRG description DRG weight mean LOS mean LOS threshold threshold
020................... Nervous System 2.1159 7.6 5.5 1 29 Infection Except Viral
Meningitis.
Area wage IME MTFapplied
Hospital Location rate index adjustment Group ASA ASA
Reynolds Army Community Hospital.... Other Urban/Rural..... .8251 1.0 $7,575.00 $7,152.00
Relative weighted product
Patient Length of stay Days above TPC amount
threshold Inlier * Outlier ** Total ***
** Outlier calculation = 33 percent of per diem weight x number of outlier days.
=.33 (DRG Weight/Geometric Mean LOS) x (Patient LOSLong Stay Threshold). =.33 (2.1159/5.5) x (3529).
=.33 (.38471) x 6 (extend to five decimal places).
=.12695 x 6 (extend to five decimal places).
=.7617 (extend to four decimal places).
*** MTFApplied ASA x Total RWP.
II. Outpatient Rates \2\ \3\ \4\
A. CMAC Rates. The CHAMPUS Maximum Allowable Charge (CMAC) rates,
established under 32 CFR 199.14(h), are used for determining the
appropriate charge for services in an itemized format, based on
Healthcare Common Procedure Coding System (HCPCS) methodology. The CMAC
rates are available on the TMA UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm. The
CMAC rate tables contain the rates for radiology, laboratory, clinic
procedures/services, and Evaluation and Management (E/M) Current Procedural Terminology (CPT) codes.
CMAC is organized by 90 distinct ``localities,'' which account for differences in geographic regions based on demographics, cost of living, and population. Each MTF Defense Military Information System identification (DMIS ID) will map to a locality code to obtain the correct rates. For the complete DMIS ID locality table please refer to the DMIS ID Web site at http://www.dmisid.com/cgidmis/default.
In each locality, there are three subtables of rates: CMAC, Component, and NonCMAC. The CMAC rate table determines the payment for individual professional services and procedures identified CPT and HCPCS codes. The Component rate table is based on component rates comprising professional, technical and global rates. The NonCMAC rate table captures pricing for procedure codes at the local or state level. Each state/locality does not have the same set of prevailing rates. When rates are pulled from the NonCMAC table, the prevailing local fee is used in all cases.
Within the CMAC tables, the rates are based not only on HCPCS but on a ``Provider Class'' based on medical specialty of the provider. Each provider is mapped to a provider class to calculate the correct rate.
B. Per ClinicVisit. With implementation of OIB, an allinclusive rate per clinic visit will no longer be charged. Instead, charges will be based on services provided and will be itemized.
C. Ambulatory Procedure Visit (APV)Per Visit \5\. APV charges are based on the CPT codes of the procedures performed. An itemized bill will be produced for the charges associated with the APV including ancillaries and anesthesia as applicable.
III. Other Rates and Charges
A. Immunization The charge for immunizations, allergen extracts, allergic condition tests, and the administration of certain medications when these services are provided in a separate immunization or shot clinic, are based on CMAC rates in cases in which such rates are available. In cases in which such rates are not available, rates will be based on the average full cost of these services, exclusive of any costs considered for purposes of any outpatient visit. A separate charge shall be made for each immunization, injection or medication administered. If there is no CMAC rate available for an immunization or injection then the flat rate of $34.00 will be billed.
B. Subsistence Rate \6\. The standard and discount rates for subsistence are available from the DoD Comptrollers Web site, Tab G: http://www.dod.mil/comptroller/ratesindex2003.html.
C. Family Member Rate $12.72 (with exception of spouses and other [[Page 62106]]
dependents of enlisted personnel in pay grades E1 through E4, who are
charged the discount meal rateSee Comptrollers Web site, Tab G:
http://www.dod.mil/comptroller/ratesindex2003.html.
D. Pharmacy \7\. All medications, both internal and external, are billable. The rates for pharmacy are based on the average full cost of these drugs. These rates will be updated quarterly. These rates in this table are based on National Drug Code (NDC) codes. This rate table may be found on the TMA UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
E. Ancillary Services. Per Procedure \8\. All Laboratory and
Radiology procedures will be billed per CMAC Rates, including those associated with a clinic visit.
F. Dental RatePer Procedure \9\.
Interagency
International and other
military Federal Other (full/
CDT/CPT Clinical service education and agency third
training sponsored party)
(IMET) patients
Dental Services ADA code weight $26.00 $60.00 $63.00 multiplier.
G. Ambulance RatePer Hour \10\.
Interagency
International and other
military Federal Other (full/
CDT/CPT Clinical service education and agency third
training sponsored party)
(IMET) patients
A0999............................ Ambulance........................... $102.00 $140.00 $147.00
H. AirEvac RatePer Trip (24hour period) 11. International Interagency & military other Federal Clinical Service education & agency Other (full/ training sponsored third party) (IMET) patients AirEvac ServicesAmbulatory.................................... $361.00 $494.00 $518.00 AirEvac ServicesLitter........................................ 1,047.00 1,435.00 1,503.00
I. Observation RatePer Hour 12. Under OIB, observation services will be billed according to applicable CPT codes.
J. Anesthesia The flat rate for anesthesia services is based on an average DoD cost of service in all MTFs. The range of HCPCS codes for anesthesia is 0010001999. The flat rate for anesthesia will be $174.00.
K. Durable Medical Equipment/Durable Medical Supplies (DME/DMS)
Durable Medical Equipment (DME) and Durable Medical Supplies (DMS) are
based on the Medicare Fee Schedule floor rate. The HCPCS codes
contained in this table are for A4212A7509, E0100E2101, K0001K0551,
L0100L8670, and V2020V2780. This rate table may be found on the TMA
UBO Web Site at http://www.tricare.osd.mil/ebc/rm_ home/ubo documentsratestables.cfm.
IV. Elective Cosmetic Surgery Procedures and Rates 13/
Current procedural Amount of
Cosmetic surgery procedure terminology (CPT)e FY 2003 charge charge
Abdominoplasty....................... 15831........................ Inpatient Charge per DRG or (a b c)
CPT.
Blepharoplasty....................... 15820, 15821, 15822, 15823... Inpatient Charge per DRG or (a b c)
CPT.
Botox Injection for rhytids.......... J0585........................ Inpatient Charge per DRG or (a b c)
CPT.
Brachioplasty........................ 15836........................ Inpatient Charge per DRG or (a b c)
CPT.
Brow Lift............................ 15824, 15839................. Inpatient Charge per DRG or (a b c)
CPT.
Buttock Lift......................... 15835........................ Inpatient Charge per DRG or (a b c)
CPT.
Canthopexy........................... 21282, 67950................. Inpatient Charge per DRG or (a b c)
CPT.
Cervicoplasty........................ 15819........................ Inpatient Charge per DRG or (a b c)
CPT.
Chemical Peel........................ 15788, 15789, 15792, 15793... Inpatient Charge per DRG or (a b c)
CPT.
Collagen Injection, subcutaneous..... 11950, 11951, 11952, 11954... Inpatient Charge per DRG or (a b c)
CPT.
Dermabrasion......................... 15780, 15781, 15782, 15783... Inpatient Charge per DRG or (a b c)
CPT.
Arm/Thigh Dermolipectomy............. 15836, 15832................. Inpatient Charge per DRG or (a b c)
CPT. [[Page 62107]]
Excision/destruction of minor benign 11400, 11401, 11402, 11403, Inpatient Charge per DRG or (a b c)
skin lesions. 11404, 11406, 11420, 11421, CPT.
11422, 11423, 11424, 11426,
11440, 11441, 11442, 11443,
11444, 11446, 17000, 17003,
17004, 17106, 17107, 17108,
17110, 17111, 17250.
Facial Rhytidectomy.................. 15824, 15825, 15826, 15828, Inpatient Charge per DRG or (a b c)
15829. CPT.
Genioplasty.......................... 21120, 21121................. Inpatient Charge per DRG or (a b c)
CPT.
Hair Restoration..................... 15775, 15776................. Inpatient Charge per DRG or (a b c)
CPT.
Hip Lift............................. 15834........................ Inpatient Charge per DRG or (a b c)
CPT.
Laser Resurfacing.................... 17999........................ Inpatient Charge per DRG or (a)
CPT.
Lipectomy Suction per region......... 15876, 15877, 15878, 15879... Inpatient Charge per DRG or (a b c f)
CPT.
Malar Augmentation................... 21270........................ Inpatient Charge per DRG or (a b c)
CPT.
Mammaplastyaugmentation............ 19318, 19324, 19325,......... Inpatient Charge per DRG or (a b)
CPT.
Mandibular or Maxillary Repositioning 21194........................ Inpatient Charge per DRG or (a b c)
CPT.
Mastopexy............................ 19316........................ Inpatient Charge per DRG or (a b c)
CPT.
Mentoplasty (Augmentation/Reduction). 21208, 21209................. Inpatient Charge per DRG or (a b c)
CPT.
Otoplasty............................ 69300........................ Inpatient Charge per DRG or (a b c)
CPT. Refractive surgery (see the following
two procedures):
Radial Keratotomy.................... 65771........................ CPT......................... (b c d)
Other Procedure (if applies to 66999........................ CPT......................... (b c d) laser or other refractive
surgery).
Rhinoplasty.......................... 30400, 30410, 30430, 30435, Inpatient Charge per DRG or (a b c)
30450, 30460, 30462. CPT.
Scar Revisions beyond CHAMPUS........ 13120, 13121, 13122, 13131, Inpatient Charge per DRG or (a b c)
13132, 13133, 13150, 13152, CPT. 13153.
Sclerotherapy........................ 36468, 36469, 36470, 36471, Inpatient Charge per DRG or (a b c)
15780, 15781, 15782, 15783, CPT. 15786.
Tattoo Removal....................... 15780, 15783, 17999.......... Inpatient Charge per DRG or (\a\ \b\
CPT. \c\)
Thigh Lift........................... 15832........................ Inpatient Charge per DRG or (\a\ \b\
CPT. \c\)
Vein Stripping....................... 37720, 37730, 37735.......... Inpatient Charge per DRG or (\a\ \b\
CPT. \c\) Notes on Cosmetic Surgery Charges:
\a\ Charges for Inpatient surgical care services are based on the cost per DRG.
\b\ Charges for outpatient surgical care services are based on the cost per CPT code.
\c\ All required DoD guidelines and instructions for APVs must be followed. An ambulatory procedure visit is
defined in DoD Instruction 6025.8, ``Ambulatory Procedure Visit (APV),'' dated September 23, 1996, as
immediate (day of procedure) preprocedure and immediate postprocedure 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 MTFestablished APU associated with the referring clinic.
\d\ Refer to Office of the Assistant Secretary of Defense (Health Affairs) policy on Vision Correction Via Laser
Surgery For NonActive Duty Beneficiaries, April 7, 2000, for further guidance on billing for these services.
The policy can be downloaded from: http://www.ha.osd.mil/policies/2000/00_003.pdf.
\e\ The attending physician is to document and record the appropriate DRG/CPT code to indicate the procedure
followed during cosmetic surgery. It is up to the physician to decide whether or not the services are considered medically necessary or elective.
\f\ Each regional lipectomy shall carry a separate charge. Regions include head and neck, abdomen, flanks, and hips.
Notes on Reimbursable Rates
\1\ 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 ASA per
RWP for use in the direct care system is comparable to procedures
used by the Centers for Medicare and Medicaid Services (CMS) and
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 above. The ASA rate used in these
cases, based on the absence of an 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.A.1.). The UBO must receive documentation of care provided in order to produce a bill.
\2\ Percentages can be applied when preparing bills for
inpatient services. Pursuant to the provisions of 10 U.S.C. 1095,
the inpatient Diagnosis Related Groups percentages are 96 % hospital
and 4% professional charges. When preparing bills for outpatient
services, professional fees are based on the E/M charges, the
hospital fees are based on the charges for ancillary services, pharmacy and supplies.
\3\ 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.
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
\4\ The following chart of MEPRS work centers are DoD approved
for outpatient itemized billing. Claims can be generated for
encounters, ancillaries, pharmacy, DME/DMS, etc. from these workcenters.
MEPRS code Clinical service BAA Internal Medicine.
[[Page 62108]]
BAB Allergy.
BAC Cardiology.
BAE Diabetic.
BAF Endocrinology (Metabolism). BAG Gastroenterology.
BAH Hematology.
BAI Hypertension.
BAJ Nephrology.
BAK Neurology.
BAL Outpatient Nutrition.
BAM Oncology.
BAN Pulmonary Disease.
BAO Rheumatology.
BAP Dermatology.
BAQ Infectious Disease.
BAR Physical Medicine.
BAS Radiation Therapy.
BAT Bone Marrow Transplant. BAU Genetic.
BAV Hyperbaric.
BBA General Surgery.
BBB Cardiovascular and Thoracic Surgery. BBC Neurosurgery.
BBD Ophthalmology.
BBE Organ Transplant.
BBF Otolaryngology.
BBG Plastic Surgery.
BBH Proctology.
BBI Urology.
BBJ Pediatric Surgery.
BBK Peripheral Vascular Surgery. BBL Pain Management.
BBM Vascular and Interventional Radiology.
BCA Family Planning.
BCB Gynecology.
BCC Obstetrics.
BCD Breast Cancer Clinic.
BDA Pediatric.
BDB Adolescent.
BDC Well Baby.
BEA Orthopedic.
BEB Cast.
BEC Hand Surgery.
BEE Orthotic Laboratory.
BEF Podiatry.
BEZ Chiropractic.
BFA Psychiatry.
BFB Psychology.
BFC Child Guidance.
BFD Mental Health.
BFE Social Work.
BFF Substance Abuse.
BGA Family Practice.
BHA Primary Care.
BHC Optometry.
BHD Audiology.
BHE Speech Pathology.
BHF Community Health.
BHG Occupational Health.
BHH TRICARE Outpatient.
BHI Immediate Care.
BIA Emergency Medical.
BKA Underseas Medicine.
BLA Physical Therapy.
BLB Occupational Therapy.
MEPRS code Other billable services DAA Pharmacy.
DBA Clinical Pathology.
DBB Anatomical Pathology.
DBD Cytogenetic Laboratory.
DBE Molecular Genetic Laboratory.
DBF Biochemical Genetic Laboratory. DCA Diagnostic Radiology.
FBI Immunizations.
FBN Hearing Conservation (MSA Billing Only).
FC Pharmacy, Laboratory and Radiology
(External Civilian Ancillary and
Support to other Military and
Federal), except in cases where
there is a specific VA/DoD MOU. FEA Ambulance.
5 Ambulatory procedure visit is defined in DoD
Instruction 6025.8, ``Ambulatory Procedure Visit (APV),'' dated
September 23, 1996, as immediate (day of procedure) preprocedure
and immediate postprocedure 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.
6 Subsistence is billed under the Medical Services
Account (MSA) Program only. The MSA office shall collect subsistence
charges from all persons, including inpatients and transient
patients not entitled to food service at Government expense. Please
refer to DoD 6010.15M, Military Treatment Facility UBO Manual,
April 1997, and the DoD 7000.14R, ``Department of Defense Financial
Management Regulation,'' Volume 12, Chapter 19 for guidance on the use of these rates.
7 Third party payers (such as insurance companies)
shall be billed for prescription services when beneficiaries who
have medical insurance obtain medications from MTFs that are
prescribed by providers both internal and 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 includes the DoDwide
average cost of the drug, calculated by lowest cost for the generic
drugs with the same dosage and strength. 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 TMA's UBO Web
site, http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
8 Charges for ancillary services requested by an
internal (associated with a clinic visit) or 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.
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 not seen by an outside provider and only come to the MTF for ancillary services.
9 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 $9.45 ($63 x .15 = $9.45).
The list of CY 2003 ADA codes and weights for dental services is
too large to include in this document. This rate table may be found
on the TMA's UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm .
10 Ambulance charges shall be based on hours of
service in 15minute increments. The rates listed in section III.G.
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 15minute increment (e.g., 31 minutes shall be charged as 45 minutes).
11 Air inflight medical care reimbursement charges
are determined by the status of the patient (ambulatory or litter)
and are per patient during a 24hour 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.
12 Observation Services are billed based on
applicable CPTs. 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.
13 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 IV. The patient shall be charged
the rate as specified in the CY 2003 reimbursable rates. The charges for elective
[[Page 62109]]
cosmetic surgery are at the full reimbursement rate (designated as
the ``Other'' rate) for inpatient care services based on the cost
per DRG or CPT. 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.)
Attachment 1.FY 2003 Adjusted Standardized Amounts (ASA) by Military Treatment Facility
DMIS ID MTF name Serv Full rate IAR rate IMET rate TPC rate
0003............... Lyster AHFt. Rucker. A $7,032 $6,676 $4,007 $7,032
0005............... Bassett ACHFt. A 7,794 7,399 4,441 7,794 Wainwright.
0006............... 3 Med GrpElmendorf F 7,624 7,237 4,344 7,624 AFB.
0009............... 56th Med GrpLuke AFB F 6,734 6,421 3,514 6,734
0014............... 60th Med GrpTravis F 10,529 9,995 6,000 10,529 AFB.
0024............... NH Camp Pendleton..... N 8,189 7,808 4,274 8,189
0028............... NH Lemoore............ N 7,554 7,171 4,304 7,554
0029............... NMC San Diego......... N 10,268 9,790 5,359 10,268
0030............... NH Twentynine Palms... N 6,820 6,502 3,559 6,820
0032............... Evans ACHFt. Carson. A 7,564 7,181 4,310 7,564
0033............... 10th Med GrpUSAF F 7,574 7,190 4,316 7,574 Academy.
0035............... NH Groton............. N 7,575 7,191 4,316 7,575
0037............... Walter Reed AMC A 10,415 9,930 5,435 10,415 Washington DC.
0038............... NH Pensacola.......... N 9,119 8,656 5,196 9,119
0039............... NH Jacksonville....... N 8,580 8,180 4,477 8,580
0042............... 96th Med GrpEglin F 9,580 9,095 5,459 9,580 AFB.
0045............... 6th Med GrpMacDill F 6,748 6,434 3,521 6,748 AFB.
0047............... Eisenhower AMCFt. A 9,312 8,839 5,306 9,312 Gordon.
0048............... Martin ACHFt. A 8,315 7,893 4,738 8,315 Benning.
0049............... Winn ACHFt. Stewart. A 7,564 7,180 4,310 7,564
0052............... Tripler AMCFt. A 10,248 9,728 5,839 10,248 Shafter.
0053............... 366th Med GrpMtn F 7,560 7,176 4,308 7,560 Home AFB.
0055............... 375th Med GrpScott F 8,671 8,268 4,525 8,671 AFB.
0056............... NH Great Lakes........ N 6,802 6,486 3,550 6,802
0060............... Blanchfield ACHFt. A 7,025 6,669 4,003 7,025 Campbell.
0061............... Ireland ACHFt. Knox. A 6,620 6,311 3,454 6,620
0064............... BayneJones ACHFt. A 6,987 6,633 3,981 6,987 Polk.
0066............... 89th Med GrpAndrews F 8,944 8,527 4,667 8,944 AFB.
0067............... NNMC Bethesda......... N 10,397 9,913 5,426 10,397
0073............... 81st Med GrpKeesler F 10,103 9,591 5,757 10,103 AFB.
0075............... Wood ACHFt. Leonard A 7,179 6,815 4,091 7,179 Wood.
0078............... 55th Med GrpOffutt F 9,972 9,466 5,682 9,972 AFB.
0079............... 99th Med GrpNellis F 6,763 6,448 3,529 6,763 AFB.
0086............... Keller ACHWest Point A 8,234 7,816 4,692 8,234
0089............... Womack AMCFt. Bragg. A 8,079 7,669 4,604 8,079
0091............... NH Camp LeJeune....... N 7,352 6,980 4,190 7,352
Beginning May 1, 2003, the rates prescribed herein superceded those
established by the Director of the Office of Management and Budget, December 9, 2002 (FR Doc. 0231024). 6
Joshua B. Bolten,
Director, Office of Management and Budget.
[FR Doc. 0327360 Filed 103003; 8:45 am]
BILLING CODE 311001P