[Federal Register Volume 59, Number 145 (Friday, July 29, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-18061]


[[Page Unknown]]

[Federal Register: July 29, 1994]


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OFFICE OF MANAGEMENT AND BUDGET

 

Cost of Hospital and Medical Care and Treatment Furnished by the 
United States; Certain Rates Regarding Recovery From Tortiously Liable 
Third Persons

    By virtue of the authority vested in the President by Section 2(a) 
of P.L. 87-693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to the 
Director of the Office of Management and Budget by Executive Order No. 
11541 of July 1, 1970 (35 FR 10737), the revised set of Department of 
Defense rates outlined below are hereby established. These rates are 
for use in connection with the recovery, from tortiously liable third 
persons, of the cost of hospital and medical care treatment furnished 
by the United States (Part 43, Chapter I, Title 28, Code of Federal 
Regulations) through three separate Federal agencies. The rates have 
been established in accordance with the requirements of OMB Circular A-
25, requiring reimbursement of the full cost of all services provided. 
The rates are established as follows:
    Department of Defense. Historic costs including purchases of 
supplies and equipment, base pay, allowances, permanent change of 
station costs, retirement pay and health benefits accrual costs, 
medical specialty pays and medical training are determined. These costs 
are then adjusted to reflect civilian and military pay raises and 
inflation to arrive at the estimated rates. An asset charge is included 
to reflect depreciation.
    For the period beginning April 1, 1994, the rates herein superseded 
those established by the Director of the Office of Management and 
Budget on October 1, 1992 (57 CFR 48642).
Leon E. Panetta,
Director, Office of Management and Budget.

 Tortiously Liable Rates, Fiscal Year 1994, April 1994 Through September
         1994--Inpatient, Outpatient and Other Rates and Charges        
------------------------------------------------------------------------
                                                                Full    
                                                           reimbursement
                                                                rate    
------------------------------------------------------------------------
I. Per Inpatient Day:                                                   
    A. Burn Center.......................................        $2,975 
    B. Inpatient Other Than Burn Center\1\                              
        Medical Care Services............................           783 
        Surgical Care Services...........................         1,082 
        Obstetrical and Gynecological Care...............         1,020 
        Pediatric Care...................................           785 
        Orthopedic Care..................................           977 
        Psychiatric Care and Substance Abuse.............           479 
        Medical Intensive Care and Coronary Care.........         1,703 
        Surgical Intensive Care..........................         1,855 
        Neonatal Intensive Care..........................         1,087 
        Organ and Bone Marrow Transplant.................         1,533 
        Same Day Surgery.................................           426 
II. Per Outpatient Visit:\2\                                            
    A. Medical Treatment Facilities......................           101 
    B. PRIMUS/NAVCARE....................................         \3\61 
III. Other Rates and Charges:                                           
    A. Hyperbaric Services:                                             
        1-60 minutes.....................................           177 
        61-120 minutes...................................           345 
        121-180 minutes..................................           512 
        181-240 minutes..................................           679 
------------------------------------------------------------------------
(Note: Charges may be prorated based on usage.)                         


----------------------------------------------------------------------------------------------------------------
                                                                                    Total dispensed    Standard 
                   Generic (trade) name                            Strength          quantity\4\        cost    
----------------------------------------------------------------------------------------------------------------
B. High Cost Medications Requested By External                                                                  
 Providers:\3\                                                                                                  
    Acyclovir (Zovirax)....................................  800mg...............  100.............         $286
    Acyclovir oint.........................................  15g.................  6 Tubes.........          161
    Aminoglutethamide (Cytadren)...........................  250mg...............  360.............          376
    Amiodarone (Cardarone).................................  200mg...............  180.............          218
    Amlodipine (Norvasc)...................................  2.5mg...............  270.............          248
    Amlodipine (Norvasc)...................................  5mg.................  270.............          252
    Astemizole (Hismanal)..................................  50mg................  90..............          109
    Auranofin (Ridaura)....................................  3mg.................  180.............          153
    Betoxolol (Betoptic)...................................  .25%................  3 btls..........          114
    Bromocriptine..........................................  2.5mg...............  270.............          454
    Buspirone (Buspar).....................................  5mg.................  270.............          121
    Buspirone (Buspar).....................................  10mg................  270.............          208
    Calcitonin (Calcimar)..................................  200 IU..............  8 vials.........          179
    Captopril (Capoten)....................................  25mg................  270.............          134
    Captopril (Capoten)....................................  50mg................  270.............          221
    Captopril (Capoten)....................................  100mg...............  270.............          333
    Carbenicillin..........................................  382mg...............  40..............          103
    Caridopa/Levodopa CR (Sinemet CR)......................  ....................  270.............          291
    Caridopa/Levodopa (Sinemet 25/100).....................  25/100..............  360.............          184
    Caridopa/Levodopa (Sinemet 25/250).....................  25/250..............  360.............          235
    Chemstrip BG II........................................  ....................  360.............          271
    Cholestyramine powder..................................  ....................  6 cans..........          151
    Cholestyramine powder light............................  ....................  6 cans..........          129
    Cimetidine.............................................  400mg...............  180.............          146
    Cimetidine.............................................  300mg...............  360.............          164
    Cimetidine syrup.......................................  ....................  3 btls..........          150
    Clemastine (Tavist)....................................  2.68mg..............  270.............          183
    Clomipramine (Anafranil)...............................  50mg................  360.............          292
    Clomipramine (Anafranil)...............................  25mg................  360.............          210
    Colestipol.............................................  5mg packets.........  360 pkt.........          274
    Cromolyn inhaler.......................................  ....................  4 btls..........          183
    Cromolyn soln (nebulizer)..............................  ....................  360 amp.........          204
    Cyclophosphamide.......................................  25mg................  360.............          360
    Cyclophosphamide.......................................  50mg................  360.............          681
    Cyclosporine...........................................  100mg...............  60..............          257
    Cyclosporine...........................................  100mg/ml sol........  3 btls..........          639
    Danazol (Danocrine)....................................  200mg...............  180.............          320
    Demeclocycline.........................................  150mg...............  60..............          145
    Desmopressin nasal soln (DDAVP)........................  ....................  20 ml...........          367
    Desmopressin nasal spray...............................  ....................  20 ml...........          328
    Diclofenac (Voltaren)..................................  75mg................  180.............          150
    Diclofenac (Voltaren)..................................  50mg................  270.............          187
    Didanosine.............................................  150mg...............  180.............          357
    Didanosine (Videx).....................................  25mg................  360.............          124
    Didanosine (Videx).....................................  100mg...............  360.............          475
    Diflucan...............................................  100mg...............  30..............          182
    Diflucan...............................................  200mg...............  30..............          298
    Diflunisal (Dolobid)...................................  500mg...............  180.............          173
    Diltiazem 60mg (Cardizem)..............................  60mg................  270.............          130
    Diltiazem CD (Cardizem CD).............................  240mg...............  90..............          135
    Diltiazem CD (Cardizem CD).............................  300mg...............  90..............          174
    Diltiazem SR...........................................  120mg...............  180.............          144
    Diltiazem SR...........................................  60mg................  180.............          111
    Diltiazem (Cardizem)...................................  120mg...............  360.............          315
    Divalproax (Depakote)..................................  250mg...............  360.............          146
    Elase ointment.........................................  ....................  6 tubes.........          157
    Enalapril..............................................  5mg.................  180.............          127
    Enalapril..............................................  20mg................  180.............          190
    Enalapril..............................................  10mg................  180.............          134
    Epoetin Alfa 2000......................................  ....................  24..............          478
    Epoetin Alfa 3000......................................  ....................  24..............          727
    Epoetin Alfa 4000......................................  ....................  24..............          979
    Estramustine (Emcyt)...................................  150mg...............  150.............          361
    Ethambutol.............................................  400mg...............  180.............          177
    Ethosuximide...........................................  250mg...............  360.............          167
    Etidronate Disodium....................................  400mg...............  90..............          164
    Etidronate Disodium (Didronel..........................  200mg...............  270.............          492
    Etoposide (VePesid)....................................  50mg................  25..............          619
    Exactech...............................................  ....................  90 days.........          450
    Famotidine (Pepcid)....................................  20mg................  180.............          152
    Fentanyl patch.........................................  100mcg..............  10..............          245
    Fentanyl patch.........................................  75mcg...............  10..............          203
    Fluconazole (Diflucan).................................  200mg...............  30..............          298
    Fluconazole (Diflucan).................................  100mg...............  30..............          182
    Fluconazole (Diflucan).................................  50mg................  30..............          116
    Fluoxetine (Prozac)....................................  20mg................  60..............          102
    Flurbiprofen (Ansaid)..................................  100mg...............  90..............          150
    Flutamide (Eulexin)....................................  125mg...............  540.............          597
    Gemfibrozil (Lopid)....................................  600mg...............  180.............          160
    Glipizide..............................................  10mg................  180.............          177
    Hemofil M..............................................  ....................  30 days.........        6,816
    Hydroxychloroquine.....................................  200mg...............  180.............          178
    Hydroxyurea (Hydrea)...................................  500mg...............  270.............          308
    Interferon (Intron A)..................................  3mu.................  12..............          287
    Isotretinoin (Accutane)................................  10mg................  60..............          133
    Isotretinoin (Accutane)................................  20mg................  60..............          158
    Isotretinoin (Accutane)................................  40mg................  60..............          182
    Itraconazole (Sporonox)................................  10mg................  30..............          127
    Leucovorin.............................................  5mg.................  100.............          166
    Leuprolide (Lupron)....................................  7.5mg...............  1...............          387
    Leuprolide (Lupron)....................................  3.75mg..............  1...............          278
    Lisinopril.............................................  10mg................  180.............          112
    Lisinopril (Prinivil)..................................  5mg.................  180.............          112
    Lomustine..............................................  40mg................  20..............          182
    Lomustine..............................................  100mg...............  20..............          400
    Lovastatin (Mevacor)...................................  20mg................  180.............          265
    Lovastatin (Mevacor)...................................  40mg................  180.............          492
    Loxapine (Loxitane)....................................  50mg................  180.............          138
    Lypressin spray (Diapid)...............................  ....................  4 btls..........          116
    Megestrol (Megace).....................................  20mg................  360.............          120
    Megestrol (Megace).....................................  40mg................  360.............          228
    Melphalan (Alkeran)....................................  2mg.................  350.............          410
    Mesalamine enema (Rowasa)..............................  500mg...............  90..............          158
    Metaproterenol neb soln................................  0.6%................  100.............          105
    Methazolamide..........................................  50mg................  270.............          166
    Methotrexate...........................................  2.5mg...............  180.............          170
    Methysergide Maleate...................................  2mg.................  180.............          182
    Mexiletine (Mexitil)...................................  200mg...............  270.............          156
    Mexiletine (Mexitil)...................................  250mg...............  270.............          185
    Mexiletine (Mexitil)...................................  150mg...............  270.............          131
    Misoprostol............................................  200mcg..............  360.............          197
    Naproxen...............................................  500mg...............  180.............          176
    Naproxen...............................................  375mg...............  270.............          216
    Naproxen...............................................  250mg...............  270.............          168
    Nicotine Transdermal System............................  21mg................  30..............          100
    Nifedipine.............................................  60mg XL.............  90..............          151
    Nifedipine.............................................  90mg XL.............  90..............          181
    Nortriptyline HCL......................................  25mg................  90..............          107
    Olsalazine (Dipentim)..................................  250mg...............  360.............          149
    Omperazole (Prilosec)..................................  20mg................  90..............          268
    One Touch Test Strips..................................  ....................  360.............          171
    Pancrelipase MT16......................................  ....................  540.............          313
    Pancrelipase (Pancrease)...............................  ....................  540.............          119
    Penicillamine..........................................  250mg...............  360.............          260
    Perphenazine...........................................  2mg.................  360.............           11
    Pravastin Sodium (Pravachol)...........................  10mg................  90..............          125
    Pravastin Sodium (Pravachol)...........................  20mg................  90..............          132
    Probucol (Lorelco).....................................  250mg...............  360.............          184
    Procarbazine (Matulane)................................  50mg................  360.............          204
    Procyclidine (Kemadrin)................................  5mg.................  360.............          113
    Pyrazinamide...........................................  500mg...............  360.............          430
    Ranitidine.............................................  150mg...............  180.............          152
    Rifampin with INH......................................  ....................  180.............          493
    Selegeline (Eldepryl)..................................  5mg.................  180.............          416
    Somatrem (Protropin)...................................  5mg.................  4...............          770
    Somatropin (Humatrope).................................  ....................  6 Vials.........        1,126
    Sucalfate (Carafate)...................................  1GM.................  360.............          183
    Sulindac...............................................  150mg...............  360.............          112
    Sulindac...............................................  200mg...............  360.............          139
    Tamoxifen (Nolvadex)...................................  10mg................  180.............          207
    Terfenadine (Seldane)..................................  ....................  180.............          124
    Ticlopidine (Ticlid)...................................  250mg...............  180.............          219
    Tocainide (Tonocard)...................................  400mg...............  270.............          181
    Tocainide (Tonocard)...................................  600mg...............  270.............          231
    Tracer BG Strips.......................................  ....................  360.............          252
    Ursidiol (Actigall)....................................  300mg...............  90..............          145
    Verapamil SR 240 (Calan SR)............................  ....................  180.............          100
    Zalcitabine (Hivid)....................................  .75mg...............  270.............          542
    Zidovudine (Retrovir)..................................  100mg...............  450.............         598 
----------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------
                                                               Cost of  
                     Service provided                          service  
------------------------------------------------------------------------
C. High Cost Services Requested By External Providers:\3\               
    X-Ray Ribs (all), per side.............................         $114
    X-Ray Hips, Bilateral..................................          116
    Upper Gastrointestinal (G.I.) study with contrast......          146
    Hysterosalpingogram....................................          128
    Mammogram, Bilateral or with localization..............          131
    Ultrasound, per study..................................          117
    Ultrasound--complete abdomen or with biopsy............          203
    Computerized Axial Tomography (CAT) scan head/brain                 
     without contrast......................................          198
    Computerized Axial Tomography (CAT) scan head/brain                 
     with contrast.........................................          223
    Computerized Axial Tomography (CAT) scan head/brain                 
     with and without contrast, or post fossa and IAM/IACS.          315
    Computerized Axial Tomography (CAT) scan chest.........          348
    Computerized Axial Tomography (CAT) scan abdomen, per               
     study.................................................          172
    Computerized Axial Tomography (CAT) scan extremity                  
     without contrast......................................          201
    Computerized Axial Tomography (CAT) scan extremity with             
     contrast..............................................          232
    Computerized Axial Tomography (CAT) scan extremity with             
     and without contrast..................................          306
    Magnetic Resonance Imaging (MRI) without contrast......          287
    Magnetic Resonance Imaging (MRI) with contrast brain...          495
    Magnetic Resonance Imaging (MRI) spine (all) chest and              
     abdomen without contrast..............................          235
    Magnetic Resonance Imaging (MRI) spine (all) with                   
     contrast..............................................          523
    Magnetic Resonance Imaging (MRI) extremities without                
     contrast..............................................          370
    Magnetic Resonance Imaging (MRI) extremities with and               
     without contrast......................................         287 
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                       Inter-         Common                        National                    
                                   classification   procedure  -------------------------------------------------
    Cosmetic surgery procedure     diseases (ICD-  terminology                                          Full    
                                         9)          (CPT)\5\            FY 94 charge\6\           reimbursement
----------------------------------------------------------------------------------------------------------------
D. Elective Cosmetic Surgery                                                                                    
 Procedures and Rates                                                                                           
    Mammaplasty..................          85.50         19325  Surgical Care Services or........        $1,082 
                                           85.32         19324  Same Day Surgery.................           426 
                                           85.31         19318  .................................  .............
    Mastopexy....................          85.60         19316  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................  .............
    Facial.......................          86.82         15824  Surgical Care Services or........         1,082 
        Rhytidectomy.............          86.22   ...........  Same Day Surgery.................           426 
    Blepharoplasty...............          08.70         15820  Surgical Care Services or........         1,082 
                                           08.44         15821  Same Day Surgery.................           426 
                                   ..............        15822  .................................  .............
                                   ..............        15823  .................................  .............
    Mentoplasty..................          76.68         21208  Surgical Care Services or........         1,082 
        (Augumentation Reduction)          76.67         21209  Same Day Surgery.................           426 
    Abdominoplasty...............          86.83         15831  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Lipectomy, suction per                 86.83         15876  Surgical Care Services or........         1,082 
     region\7\.                                                                                                 
                                   ..............        15877  Same Day Surgery.................           426 
                                   ..............        15878  .................................  .............
                                   ..............        15879  .................................  .............
    Rhinoplasty..................          21.87         30400  Surgical Care Services or........         1,082 
                                           21.86         30410  Same Day Surgery.................           426 
    Scar revisions beyond CHAMPUS          86.84          1587  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Mandibular or Maxillary                76.41         21194  Surgical Care Services or........         1,082 
     Repositioning.                                                                                             
                                                                Same Day Surgery.................           426 
    Minor Skin Lesions\8\........          86.30          1578  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Dermabrasion.................          86.25         15780  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Hair Restoration.............          86.64         15775  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Removing Tatoos..............          86.25         15780  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Chemical Peel................          86.24         15790  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Arm/Thigh Dermolipectomy.....          86.83          1583  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
    Brow Lift....................           86.3         15839  Surgical Care Services or........         1,082 
                                                                Same Day Surgery.................           426 
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                Inpatient rate                                           Items included                         
----------------------------------------------------------------------------------------------------------------
E. Immunization..............................  $18.                                                             
F. Clinical Services by Types of Service/Care                                                                   
 Provided:                                                                                                      
    Medical Care Services....................  Internal Medicine, Cardiology, Dermatology, Endocrinology,       
                                                Gastroenterology, Hematology, Nephrology, Neurology, Oncology,  
                                                Pulmonary and Upper Respiratory Disease, Rheumatology, Physical 
                                                Medicine, Clinical Immunology, HIV-III Acquired Immune          
                                                Deficiency Syndrome (AIDS), Infectious Disease, Allergy, and    
                                                Medical Care not elsewhere classified. Includes Family Practice 
                                                Medical Care.                                                   
    Surgical Care Services...................  General Surgery, Cardiovascular and Thoracic Surgery,            
                                                Neurosurgery, Ophthalmology, Oral Surgery, Otorhinolaryngology, 
                                                Pediatric Surgery, Plastic Surgery, Proctology, Urology,        
                                                Peripheral Vascular Surgery, Trauma Center, Head and Neck       
                                                Surgery, and Surgical Care not elsewhere classified. Includes   
                                                Family Practice Surgical Care.                                  
    Obstetrical and Gynecological Care.......  Included Family Practice Obstetrics and Gynecology.              
    Pediatric Care...........................  Pediatrics, Nursery, Adolescent Pediatrics and Pediatric Care not
                                                elsewhere classified. Includes Family Practice Pediatric and    
                                                Nursery Care.                                                   
    Orthopedic Care..........................  Orthopedics, Podiatry and Hand Surgery. Includes Family Practice 
                                                Orthopedic Care.                                                
    Psychiatric Care and Substance Abuse       Includes Family Practice Psychiatric Care.                       
     Rehabilitation.                                                                                            
    Medical Intensive Care/Coronary Care.....  Self-Explanatory.                                                
    Surgical Intensive Care..................  Self-Explanatory.                                                
    Neonatal Intensive.......................  Self-Explanatory.                                                
    Organ and Bone Marrow Transplants........  Self-Explanatory.                                                
    Same Day Surgery.........................  Self-Explanatory.                                                
----------------------------------------------------------------------------------------------------------------
Notes on Reimbursable Rates                                                                                     
                                                                                                                
\1\Daily percentages are applied to both inpatient and outpatient services provided when billing third party    
  payers (such as insurance companies). Pursuant to the provisions of 10 U.S.C. 1095, the inpatient daily       
  percentages are 55 percent hospital, 5 percent physician, 40 percent ancillary. The outpatient daily          
  percentages are 57 percent hospital, 10 percent physicians and 33 percent ancillary.                          
\2\DOD civilian employees located in overseas areas shall be rendered a bill when services are performed.       
  Payment is due 60 days from the date of the bill.                                                             
\3\Charges for PRIMUS/NAVCARE and high cost medications/services requested by external providers (Physicians,   
  Dentists, etc.) are only relevant to the Third Party Collection Program. Third party payers (such as insurance
  companies) shall be billed for high cost services in those instances in which non-active duty eligible        
  beneficiaries have medical insurance and are seen by providers external to a Military Medical Treatment       
  Facility (MTF) obtain the prescribed service or medication from an MTF. Eligible beneficiaries are not        
  personally liable for this cost and shall not be billed by the MTF. The standard cost of high cost medications
  includes the cost of the drugs and dispensing services.                                                       
\4\All quantities shown are tablets unless otherwise stated. The third party charge is only for the strengths   
  and the dosage cited. Charges will vary if the strengths and dosage are changed. The method of computing      
  standard costs to be charged for high cost medications is actual cost to the pharmacy, plus a 30 percent      
  dispensing fee. Only medications listed in this schedule may be billed. If a different dose is issued for a   
  medication that is listed, only bill if the cost is $100 or more.                                             
\5\The attending physician is to complete the common procedure terminology code to indicate the appropriate     
  procedure followed during domestic surgery.                                                                   
\6\Cosmetic surgery rates will be charged dependents of active duty members, retirees, and their dependents and 
  survivors. The patient shall be charged the rate as specified in the FY 1994 reimbursable rates for an episode
  of care. The charges for elective cosmetic surgery are at the full reimbursement rate (designated as the other
  rate) in section 1-2, page 1-7 entitled Inpatient and Outpatient Rates). The patient will be responsible for  
  both the cost of the implant(s) and prescribed rates.                                                         
Note: The implants and procedures used for the augmentation mammaplasty are in compliance with Federal Drug     
  Administration guidelines.                                                                                    
\7\Each regional lipectomy will carry a separate charge. Regions include head and neck, abdomen, flanks, and    
  hips.                                                                                                         
\8\These procedures are inclusive in the minor skin lesions. However, CHAMPUS separates them as noted here. All 
  charges are for the entire treatment regardless of the number of visits required.                             

[FR Doc. 94-18061 Filed 7-28-94; 8:45 am]
BILLING CODE 3110-01-M