[Federal Register Volume 60, Number 195 (Tuesday, October 10, 1995)]
[Notices]
[Pages 52655-52659]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-24950]



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DEPARTMENT OF DEFENSE

Office of the Secretary


Medical and Dental Reimbursement Rates for Fiscal Year 1996

    Notice is hereby given that the Deputy Chief Financial Officer in a 
memorandum dated September 22, 1995, established the following 
reimbursement rates for inpatient and outpatient medical care to be 
provided in FY 1996. These rates are effective October 1, 1995.

            Inpatient Outpatient and Other Rates and Charges            
------------------------------------------------------------------------
                                                   Interagency          
                                    International   and other           
                                       military      Federal            
         Per inpatient day          education and     agency      Other 
                                       training     sponsored           
                                        (IMET)       patients           
------------------------------------------------------------------------
                       I. Inpatient Rates \1\ \2\                       
                                                                        
------------------------------------------------------------------------
A. Burn Center....................       $1,871        $3,564     $3,794

[[Page 52656]]
                                                                        
B. Surgical Care Services                                               
 (Cosmetic Surgery)...............          773         1,472      1,567
C. All Other Inpatient Services                                         
 (Based on Diagnosis Related                                            
 Groups (DRG) Charges \3\)                                              
------------------------------------------------------------------------



1. FY 1996 Direct Care Inpatient Reimbursement Rates

------------------------------------------------------------------------
                                                                 Other  
       Adjusted standard amount           IMET    Interagency    (full) 
                                                               3rd party
------------------------------------------------------------------------
Large Urban..........................     $2,387      $4,452      $4,713
Other Urban/Rural....................      2,284       4,450       4,745
Overseas.............................      2,316       5,707       6,038
------------------------------------------------------------------------

2. Overview

    The FY 1996 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 involved. The 
average costs per Relative Weighted Product (RWP) for large urban, 
other urban/rural and overseas facilities will be published annually as 
an inpatient standardized amount. (See item 1 above). A ``relative 
weighted product'' for each DRG case to apply to the standardized 
amount will be determined from the DRG weights published annually for 
hospital reimbursement rates under the Civilian Health and Medical 
Program of the Uniformed Services (CHAMPUS) pursuant to 32 CFR 
199.14(a)(1) with adjustments for outliers. Standardized amounts will 
be adjusted for area wage differences and indirect medical education. 
An example of how to apply DoD costs to a DRG standardized weight to 
arrive at DoD costs is contained in part 3 of Section I.C., below.

3. Example of Adjusted Standardized Amounts for Procedures Performed

Large Urban Area--Example

    a. The cost to be recovered is DoD's cost for medical services 
provided in a large urban area. Billings will be at the third party 
rate.
    b. DRG 020: Nervous System infection except viral meningitis. 
Relative Weighted Product for an inlier case is the CHAMPUS weight of 
2.0327.
    c. The DoD adjusted standardized amount to be recovered is $4,713 
(i.e., the third party rate as shown in the table).
    d. DoD cost to be recovered at a non-teaching hospital with area 
wage index of 1.0 is the RWP factor (2.0327) in item 3.b., above, times 
the amount ($4,713) in 3.c., above.
    Cost to be recovered is $9,580.

----------------------------------------------------------------------------------------------------------------
                                                                                        Interagency             
                                                                         International   and other              
                                                                            military      Federal               
            Meprs code \4\                Per visit clinical services    education and     agency       Other   
                                                                            training     sponsored              
                                                                             (IMET)       patients              
----------------------------------------------------------------------------------------------------------------
                                          II. Outpatient Rates \1\ \2\                                          
                                                                                                                
----------------------------------------------------------------------------------------------------------------
A. Medical Care:                                                                                                
    BAA                                 Internal Medicine..............           $79          $154         $163
    BAB                                 Allergy........................            27            53           56
    BAC                                 Cardiology.....................            56           109          116
    BAE                                 Diabetes.......................            34            66           70
    BAF                                 Endocrinology..................            73           143          152
    BAG                                 Gastroenterology...............            92           179          190
    BAH                                 Hematology.....................           130           253          269
    BAI                                 Hypertension...................            29            57           60
    BAJ                                 Nephrology.....................           111           216          230
    BAK                                 Neurology......................            86           166          177
    BAL                                 Nutrition......................            24            47           51
    BAM                                 Oncology.......................            76           148          157
    BAN                                 Pulmonary Disease..............            99           193          205
    BAO                                 Rheumatology...................            71           139          147
    BAP                                 Dermatology....................            48            94          100
    BAQ                                 Infectious Disease.............            67           130          139
    BAR                                 Physical Medicine..............            64           124          132
B. Surgical Care:                                                                                               
    BBA                                 General Surgery................            93           181          193
    BBB                                 Cardiovascular/Thoracic Surgery            89           172          183
    BBC                                 Neurosurgery...................           110           215          228
    BBD                                 Ophthalmology..................            64           123          131
    BBE                                 Organ Transplant...............           127           246          262
    BBF                                 Otolaryngology.................            73           141          150
    BBG                                 Plastic Surgery................            82           159          170
    BBH                                 Proctology.....................            77           150          159
    BBI                                 Urology........................            84           164          174
    BBJ                                 Pediatric Surgery..............            61           118          125

[[Page 52657]]
                                                                                                                
C. Obstetrical and Gynecological (OB-                                                                           
 GYN):                                                                                                          
    BCA                                 Family Planning................            42            82           87
    BCB                                 Gynecology.....................            57           111          118
    BCC                                 Obstetrics.....................            55           106          113
D. Pediatric Care:                                                                                              
    BDA                                 Pediatric......................            43            83           88
    BDB                                 Adolescent.....................            42            81           86
    BDC                                 Well Baby......................            31            60           64
E. Orthopaedic Care:                                                                                            
    BEA                                 Orthopaedic....................            79           154          163
    BEB                                 Cast Clinic....................            33            65           69
    BEC                                 Hand Surgery...................            33            65           69
    BEE                                 Orthopaedic Appliance..........            54           105          112
    BEF                                 Podiatry.......................            38            74           79
    BEZ                                 Chiropractic Clinic............            24            46           49
F. Psychiatric and/or Mental Health                                                                             
 Care:                                                                                                          
    BFA                                 Psychiatry.....................            80           155          165
    BFB                                 Psychology.....................            65           127          135
    BFC                                 Child Guidance.................            27            53           56
    BFD                                 Mental Health..................            57           112          119
    BFE                                 Social Work....................            62           121          129
    BFF                                 Substance Abuse Rehabilitation.            48            93           98
G. Primary Medical Care:                                                                                        
    BGA                                 Family Practice................            51            99          105
    BHA                                 Primary Care...................            50            96          102
    BHB                                 Medical Examination............            45            88           93
    BHC                                 Optometry......................            35            67           71
    BHD                                 Audiology Clinic...............            28            54           57
    BHE                                 Speech Pathology...............            42            82           88
    BHF                                 Community Health...............            39            76           80
    BHG                                 Occupational Health............            41            79           84
    BHI                                 Immediate Care Clinic..........            67           131          139
H. Emergency Medical Care: BIA          Emergency Care Clinic..........            79           153          163
I. Flight Medicine Clinic: BJA          Flight Medicine................            73           142          151
J. Underseas Medicine Care: BKA         Underseas Medicine Clinic......            32            61           65
K. Rehabilitative Services:                                                                                     
    BLA                                 Physical Therapy...............            24            46           49
    BLB                                 Occupational Therapy...........            47            91           96
    BLC                                 Neuromuscularskeletal Screening            18            35           37
L. Same Day Surgery                     ...............................           378           721          767
                                                                                                                
----------------------------------------------------------------------------------------------------------------
                                          III. Other Rates and Charges                                          
                                                                                                                
----------------------------------------------------------------------------------------------------------------
                                        A. Immunizations...............             9            17           18
                                        B. Hyperbaric Services                                                  
                                        1-60 minutes...................           113           219          233
                                        61-120 minutes.................           221           430          452
                                        121-180 minutes................           330           640          671
                                        181-240 minutes................           438           851          889
                                        Each Additional Hour...........           113           219          233
                                                                                                                
                                 (Note: Charges may be prorated based on usage)                                 
                                                                                                                
                                        C. Family Member Rate (formerly          9.70                           
                                         Military Dependents Rate).                                             
                                        D. Third Party Drug                                                     
                                         Reimbursement Rates \5\                                                
                                                                                                                
   The FY 1996 third party drug reimbursement rates are for prescriptions requested by external providers and   
   obtained at the Military Treatment Facility. The third party drug reimbursement rates are too voluminous to  
    include in this notice. A complete listing of these rates, however, is available on request from the OASD   
                        (Health Affairs) action officer, LCDR Pat Kelly [(703) 756-8910].                       
                                                                                                                
                                        E. High Cost Services Requested                                         
                                         by External Providers \6\                                              
                                                                                                                

[[Page 52658]]
                                                                                                                
 The FY 1996 high cost services requested by external providers are too voluminous to include in this notice. A 
complete listing of these rates, however, is available on request from the OASD (Health Affairs) action officer,
                                        LCDR Part Kelly [(703) 756-8910].                                       
                                                                                                                
                                        F. Elective Cosmetic Surgery                                            
                                         Procedures and Rates                                                   
----------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------------------
                                           International    Current                                                                                     
                                          classification   procedural                                                                          Amount of
       Cosmetic surgery procedure         diseases (ICD-  terminology                            FY 1996 charge \8\                             charge  
                                                9)         (CPT) \7\                                                                                    
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mammaplasty.............................          85.50         19325  Surgical Care Services or............................................        (a) 
                                                  85.32         19324  Same Day Surgery.....................................................        (b) 
                                                  85.31         19318                                                                                   
Mastopexy...............................          85.60         19316  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Facial Rhytidectomy.....................          86.82         15824  Surgical Care Services or............................................        (a) 
                                                  86.22                Same Day Surgery.....................................................        (b) 
Blepharoplasty..........................          08.70         15820  Surgical Care Services or............................................        (a) 
                                                  08.44         15821  Same Day Surgery.....................................................        (b) 
                                                                15822                                                                                   
                                                                15823                                                                                   
Metoplasty (Augmentation Reduction).....          76.68         21208  Surgical Care Services or............................................        (a) 
                                                  76.67         21209  Same Day Surgery.....................................................        (b) 
Abdominoplasty..........................          86.83         15831  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Lipectomy, suction per region 9.........          86.83         15876  Surgical Care Services or............................................        (a) 
                                                                15877  Same Day Surgery.....................................................        (b) 
                                                                15878                                                                                   
                                                                15879                                                                                   
Rhinoplasty.............................          21.87         30400  Surgical Care Services or............................................        (a) 
                                                  21.86         30410  Same Day Surgery.....................................................        (b) 
Scar revisions beyond CHAMPUS...........          86.84         1578   Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Mandibular or Maxillary Repositioning...          76.41         21194  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Minor Skin Lesions 10...................          86.30         1578   Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Dermabrasion............................          86.25         15780  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Hair Restoration........................          86.64         15775  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Removing Tatoos.........................          86.25         15780  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Chemical Peel...........................          86.24         15790  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Arm/Thigh Dermolipectomy................          86.83         1583   Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
Brow Lift...............................           86.3         15839  Surgical Care Services or............................................        (a) 
                                                                       Same Day Surgery.....................................................        (b) 
--------------------------------------------------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                                                                        Interagency             
                                                                         International   and other              
                                                                            military      Federal               
             Meprs code 4                 Per visit clinical services    education and     agency       Other   
                                                                            training     sponsored              
                                                                             (IMET)       patients              
----------------------------------------------------------------------------------------------------------------
                                                                                                                
                                        G. Dental Rate                                                          
N/A                                     Dental Services................           $14           $27          $29
                                                                                                                
 Dental service charges are based on a Composite Time Value. Provider should calculate the charges based on the 
                                 time value of the procedure times the CTV rate.                                
                                                                                                                
                                        H. Ambulance Rate                .............  ...........  ...........
N/A                                     Ambulance Service..............            35            68           72
                                                                                                                
  Ambulance charges are based on hours of service. Provider should calculate the charges based on the number of 
                 hours (or fraction thereof) that the ambulance is logged out on a patient run.                 
                                                                                                                
----------------------------------------------------------------------------------------------------------------


[[Page 52659]]


Notes on Cosmetic Surgery Changes

    a Charges for Surgical Care Services contained in Section 
I.B. (See Notes 8 through 10 on reimbursable rates for further 
details.)
    b Charges for Same Day Surgery are contained in Section 
II.L. (See Notes 8 through 10 on reimbursable rates for further 
details.)

Notes on Reimbursable Rates

    1 Percentages are applied to both inpatient and outpatient 
services provided when billing third party payers (e.g., insurance 
companies). Pursuant to the provisions of 10 U.S.C. 1095, the 
inpatient Diagnosis Related Groups are 96 percent hospital and 4 
percent professional fee. The outpatient per visit percentages are 
58 percent hospital, 29 percent ancillary and 13 percent 
professional
    2 DoD civilian employees located in overseas areas shall be 
render a bill when services are performed. Payment is due 60 days 
from the date of the bill.
    3 The cost of DRG (Diagnosis Related Groups) is based on 
the inpatient full reimbursement rate per hospital discharge, 
weighted to reflect the intensity of the principal diagnosis 
involved. The adjusted standardized amounts (ASA) per Relative 
Weighted Product (RWP) for use in the Direct Care System will be 
comparable to procedures utilized by Health Care Financing 
Administration (HFCA) and the Civilian Health and Medical Program 
for the Uniformed Services (CHAMPUS). These expenses include all 
direct care expenses associated with direct patient care. The 
average cost per relative weight product for large urban, other 
urban/rural, and overseas will be published annually as an inpatient 
standardized amount and will include the cost of inpatient 
professional services. The DRG rates will apply to reimbursement 
from all sources, not just third party payers.
    4 The Medical Expense and Performance Reporting System 
(MEPRS) code is a three digit code which defines the summary account 
and the subaccount within a functional category in the DoD medical 
system. An example of this hierarchical arrangement is as follows:

------------------------------------------------------------------------
 Outpaitnet Care (Functional Category)              Meprs code          
------------------------------------------------------------------------
Medical Care (Summary Account).........  BA                             
Internal Medicine (Subaccount).........  BAA                            
------------------------------------------------------------------------

MEPRS codes are used to ensure that consistent expense and operating 
performance data is reported in the DoD military medical system.
    5 High Cost prescription 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 prescriptions in 
those instances in which dependents who have medical insurance, seen 
by provides external to a Military Medical Treatment Facility (MTF), 
obtain the prescribed medication from an MTF. Eligible beneficiaries 
(family members or retirees with medical insurance) are not 
personally liable for this cost and shall not be billed by the MTF. 
A third party payer may be billed if the total prescription costs in 
a day exceed $25.00 when bundled together. The standard cost of high 
cost medications include the cost of the drugs plus a dispensing 
fee, per prescription. The prescription cost is calculated by 
multiplying the number of units (tablets, capsules, etc.) times the 
unit cost and adding a $7.00 dispensing fee per prescription.
    6 Charges for high cost 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 dependents who have medical insurance, seen by 
provides external to a Military Medical Treatment Facility (MTF), 
obtain the prescribed service from an MTF. Eligible beneficiaries 
(family members or retirees with medical insurance) are not 
personally liable for this cost and shall not be billed by the MTF. 
A third party payer may be billed if the total ancillary services 
costs in a day exceed $25,00 when bundled together.
    7 The attending physical is to complete the Physicians' 
Current Procedural Terminology code to indicate the appropriate 
procedure followed during cosmetic surgery. The appropriate rate 
will be applied depending on the admission type of the patient, 
e.g., outpatient surgical, same day/ambulatory surgery, or surgical 
care services.
    8 Family members of active duty personnel, retirees and 
their family members, and survivors will be charged cosmetic surgery 
rates. The patient shall be charged the rate as specified in the FY 
1996 reimbursable rates for an episode of care. The charges for 
elective cosmetic surgery are at the full reimbursement rate 
(designated as the ``Other'' rate) for Surgical Care Services in 
Section I.B., or Same Day Surgery as contained in Section II.L. of 
this attachment. The patient will be responsible for both the cost 
of the implant(s) in addition to the prescribed cosmetic surgery 
rates.

    Note: The implants and procedures used for the augmentation 
mammaplasty are in compliance with Federal Drug Administration 
Guidelines.

    9 Each regional lipectomy will carry a separate charge. 
Regions include head and neck, abdomen, flanks, and hips.
    10 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: October 2, 1995.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 95-24950 Filed 10-6-95; 8:45 am]
BILLING CODE 5000-04-M