[Federal Register Volume 59, Number 70 (Tuesday, April 12, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-8728]


[[Page Unknown]]

[Federal Register: April 12, 1994]


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DEPARTMENT OF DEFENSE

Office of the Secretary

 

Medical and Dental Reimbursements Rates for Period April 1, 1994 
through September 30, 1994 (Fiscal Year 1994)

    Notice is hereby given that the Deputy Chief Financial Officer of 
the Department of Defense, in a memorandum of March 10, 1994, 
established the following reimbursement rates for inpatient and 
outpatient medical and dental care to be provided during the period of 
April 1, 1994 through September 30, 1994.

Inpatient, Outpatient and Other Rates and Charges

                   I.--Inpatient and Outpatient Rates                   
                  [Notes to appear at end of document]                  
------------------------------------------------------------------------
                           International    Interagency                 
                             military      other federal                
    Per inpatient day      education and      agency           Other    
                             training        sponsored                  
                              (IMET)         patients                   
------------------------------------------------------------------------
A. Burn center..........          $1,735          $2,795          $2,975
B. Inpatient other than                                                 
 burn center\1\.........  ..............  ..............  ..............
Medical care services...             329             737             783
Surgical care services..             457           1,025           1,082
Obstetrical and                                                         
 gynecological care.....             430             965           1,020
Pediatric care..........             330             740             785
Orthopedic care.........             412             924             977
Psychiatric care and                                                    
 substance abuse........             198             444             479
Medical intensive care                                                  
 and coronary care......             724           1,623           1,703
Surgical intensive care.             789           1,769           1,855
Neonatal intensive care.             459           1,029           1,087
Organ and bone marrow                                                   
 transplant.............             651           1,460           1,533
Same day surgery........             179             401             426
                                                                        
                                                                        
    (See section II, item H, which outlines the types of services/care  
     provided within each inpatient area.)                              
                                                                        
II. Per Outpatient                                                      
 Visit:                                                                 
    A. Medical treatment                                                
     facilities.........             $47          \2\$95            $101
    B. PRIMUS/NAVCARE...             N/A             N/A           \3\61
III. Other Rates and                                                    
 Charges:...............                                                
    A. Hyperbaric                                                       
     Services:..........                                                
        1-60 minutes....             $83            $167            $177
        61-120 minutes..             161             325             345
        121-180 minutes.             239             482             512
        181-240 minutes.             317             639             679
(Note: Charges may be                                                   
 prorated based on                                                      
 usage)                                                                 
    B. Military                                                         
     Dependents.........  ..............            9.30  ..............
    C. Per FAA Air                                                      
     Traffic Controller                                                 
     Examination........             N/A              96             N/A
------------------------------------------------------------------------


                           D. High Cost Medications Requested by External Providers\3\                          
                                      [Notes to appear at end of document]                                      
----------------------------------------------------------------------------------------------------------------
                                                                                  Total dispensed      Standard 
                  Generic (trade) name                         Strength             quantity\4\          cost   
----------------------------------------------------------------------------------------------------------------
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 bottles...........          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 bottles...........          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 bottles...........          183
Cromolyn soln (nebulizer)..............................  ....................  360 amp.............          204
Cyclophosphamide.......................................  25mg................  360.................          360
Cyclophosphamide.......................................  50mg................  360.................          681
Cyclosporine...........................................  100mg...............  60..................          257
Cyclosporine...........................................  100mg/ml sol........  3 bottles...........          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 bottles...........          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.................          111
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
----------------------------------------------------------------------------------------------------------------


        E. High Cost Services Requested by External Providers\3\        
                  [Notes to appear at end of document]                  
------------------------------------------------------------------------
                   Service provided                     Cost of service 
------------------------------------------------------------------------
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
------------------------------------------------------------------------


                                                    F. Elective Cosmetic Surgery Procedures and Rates                                                   
                                                          [Notes to appear at end of document]                                                          
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        International      Common                                                                       
                                                       classification     procedure                                                             Full    
             Cosmetic surgery procedure                diseases (ICD-    terminology               Fiscal year 1994 charge\6\              reimbursement
                                                             9)           (CPT)\5\                                                                      
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mammaplasty..........................................           85.50           19325  Surgical care services............................       $1,082  
                                                                85.32           19324  or................................................               
                                                                85.31           19318  Same day surgery..................................          426  
Mastopexy............................................           85.60           19316  Surgical care services............................        1,082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Facial rhytidectomy..................................           86.82           15824  Surgical care services............................        1,082  
                                                                86.22                  or................................................               
                                                                                       Same day surgery..................................          426  
Blepharoplasty.......................................           08.70           15820  Surgical care services............................        1,082  
                                                                08.44           15821  or................................................               
                                                                                15822  Same day surgery..................................          426  
                                                                                15823  ..................................................               
Mentoplasty (augumentation reduction)................           76.68           21208  Surgical care services............................        1,082  
                                                                76.67           21209  or................................................               
                                                                                       Same day surgery..................................          426  
Abdominoplasty.......................................           86.83           15831  Surgical care services............................        1,082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Lipectomy, suction per region\7\.....................           86.83           15876  Surgical care services............................        1,082  
                                                                                15877  or................................................               
                                                                                15878  Same day surgery..................................          426  
                                                                                15879  ..................................................               
Rhinoplasty..........................................           21.87           30400  Surgical care services............................        1,082  
                                                                21.86           30410  or................................................               
                                                                                       same day surgery..................................          426  
Scar revisions beyong CHAMPUS........................           86.84            1578  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Mandibular or maxillary repositioning................           76.41           21194  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Minor skin lesions\8\................................           86.30            1578  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Dermabrasion.........................................           86.25           15780  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Hair restoration.....................................           86.64           15775  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Removing tatoos......................................           86.25           15780  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Chemical peel........................................           86.24           15790  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Arm/thigh dermolipectomy.............................           86.83          1583--  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
Brow lift............................................            86.3           15839  Surgical care services............................         1082  
                                                                                       or................................................               
                                                                                       Same day surgery..................................          426  
--------------------------------------------------------------------------------------------------------------------------------------------------------

G. Immunizations--$18

          H. Clinical Services By Type of Service/Care Provided         
------------------------------------------------------------------------
     Inpatient rate                       Items included                
------------------------------------------------------------------------
Medical Care Services..  Internal Medicine, Cardiology, Dermathology,   
                          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          Includes Family Practice, Obstetrics and       
 Gynecological Care.      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     Includes Family Practice Psychiatric Care.     
 Substance Abuse                                                        
 Rehabilitation.                                                        
Medical Intensive Care/  Self-Explanatory.                              
 Coronary Care.                                                         
Surgical Intensive Care  Self-Explanatory.                              
Neonatal Intensive.....  Self-Explanatory.                              
Organ and Bone Marrow    Self-Explanatory.                              
 Transplants.                                                           
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) and 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 standards 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 cosmetic surgery.
    \6\Cosmetic surgery rates will be charged for 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 I, ``Inpatient and Outpatient Rates'' and 
Section II, ``Per Outpatient Visit''). 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 
mammoplasty 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.

    Dated: April 7, 1994.
Patricia L. Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 94-8728 Filed 4-11-94; 8:45 am]
BILLING CODE 5000-04-M