Federal Register, Volume 62 Issue 201 (Friday, October 17, 1997)

[Federal Register Volume 62, Number 201 (Friday, October 17, 1997)]
[Notices]
[Pages 54131-54138]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-27629]

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OFFICE OF MANAGEMENT AND BUDGET

Cost of Hospital and Medical Care 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 Pub. 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 three sets of rates outlined
below are hereby established. These rates are for use in connection
with the recovery, from tortiously liable third persons, of the cost of
hospital and medical care and treatment furnished by the United States
(Part 43, Chapter I, Title 28, Code of Federal Regulations) through
three separate Federal agencies. The rates have been established in
accordance with the requirements of OMB Circular A-25, requiring
reimbursement of the full cost of all services provided. The rates are
established as follows:

1. Department of Defense

The Fiscal Year 1998 (FY98) Department of Defense (DoD)
reimbursement rates for inpatient, outpatient, and other services are
provided in accordance with Section 1095 of title 10, United States
Code. Due to size, the sections containing the Drug Reimbursement Rates
(Section III.D) and the rates for Ancillary Services Requested by
Outside Providers (Section III.E) are not included in this package. The
Office of the Assistant Secretary of Defense (Health Affairs) will
provide these rates upon request. The medical and dental service rates
in this package (including the rates for ancillary services,
prescription drugs or other procedures requested by outside providers)
are effective October 1, 1997.

2. Health and Human Services

The sum of obligations for each cost center providing medical
service is broken down into amounts attributable to inpatient care on
the basis of the proportion of staff devoted to each cost center. Total
inpatient costs and outpatient costs thus determined are

[[Page 54132]]

divided by the relevant workload statistic (inpatient day, outpatient
visit) to produce the inpatient and outpatient rates. In calculation of
the rates, the Department's unfunded retirement liability cost and
capital and equipment depreciation cost were incorporated to conform to
requirements set forth in OMB Circular A-25. In addition, each cost
center's obligations include costs for certain other accounts, such as
Medicare and Medicaid collections and Contract Health funds used to
support direct program operation. Certain cost centers that primarily
support workload outside of the directly operated hospitals or clinics
(public health nursing, public health nutrition, health education) were
excluded this year as not being a part of the traditional cost of
hospital operations and not contributing directly to the inpatient and
outpatient visit workload. Overall, these rates reflect a more accurate
indication of the cost of care in HHS facilities.
In addition, separate rates per inpatient day and outpatient visit
were computed for Alaska and the rest of the United States. This gives
proper weight to the higher cost of operating medical facilities in
Alaska.

3. Department of Veterans Affairs

Actual direct and indirect costs are compiled by type of care for
the previous year, and facility overhead costs are added. Adjustments
are made using the budgeted percentage changes for the current year and
the budget year to compute the base rate for the budget year. The
budget year base rate is then adjusted by estimated costs for
depreciation of buildings and equipment, central office overhead,
Government employee retirement benefits, and return on fixed assets
(interest on capital for land, buildings, and equipment (net book
value)), to compute the budget year tortiously liable reimbursement
rates. Also shown for the tortiously liable inpatient per diem rates
are breakdowns into three cost components: Physician; Ancillary; and
Nursing, Room, and Board. As with the total per diem rates, these
breakdowns are calculated from actual data by type of care.
The interagency rates shown are to be used when VA medical care or
service is furnished to a beneficiary of another Federal agency, and
that care or service is not covered by an applicable local sharing
agreement. Government employee retirement benefits and return on fixed
assets are not included in the interagency rates, but in all other
respects the interagency rates are the same as the tortiously liable
rates.
Inpatient charges will be at the per diem rates shown for the type
of bed section or discrete treatment unit providing the care.
Prescription Filled charge in lieu of the Outpatient Visit rate will be
charged when the patient receives no service other than the Pharmacy
outpatient service. This charge applies whether the patient receives
the prescription in person or by mail.
When medical care or service is obtained at the expense of the
Department of Veterans Affairs from a non-VA source, the charge for
such care or service will be the actual amount paid by the VA for that
care or service.

1. Department of Defense

For the Department of Defense, effective October 1, 1997 and
thereafter:

Inpatient, Outpatient and Other Rates and Charges

I. Inpatient Rates ^{1 2}

1. FY98 Direct Care Inpatient Reimbursement Rates

----------------------------------------------------------------------------------------------------------------
Other (Full/Third
Adjusted standard amount IMET interagency party)
----------------------------------------------------------------------------------------------------------------
Large Urban..................................................... $2,199.00 $4,131.00 $4,372.00
Other Urban/Rural............................................... 2,194.00 4,215.00 4,499.00
Overseas........................................................ 2,450.00 5,614.00 5,960.00
----------------------------------------------------------------------------------------------------------------

2. Overview
The FY98 inpatient rates are based on the cost per DRG, which is
the inpatient full reimbursement rate per hospital discharge weighted
to reflect the intensity of the principal diagnosis, secondary
diagnoses, procedures, patient age, etc. involved. The average cost per
Relative Weighted Product (RWP) for large urban, other urban/rural, and
overseas facilities will be published annually as an inpatient adjusted
standardized amount (ASA) (see paragraph I.C.1., above). The ASA will
be applied to the RWP for each inpatient case, determined from the DRG
weights, outlier thresholds, and payment rules published annually for
hospital reimbursement rates under the Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS) pursuant to 32 CFR
199.14(a)(1), including adjustments for length of stay (LOS) outliers.
The published ASAs will be adjusted for area wage differences and
indirect medical education (IME) for the discharging hospital. An
example of how to apply DoD costs to a DRG standardized weight to
arrive at DoD costs is contained in paragraph I.C.3., below.
3. Example of Adjusted Standardized Amounts for Inpatient Stays
Figure 1 shows examples for a nonteaching hospital in a Large Urban
Area.

[[Page 54133]]

a. The cost to be recovered is DoD's cost for medical services
provided in the nonteaching hospital located in a large urban area.
Billings will be at the third party rate.
b. DRG 020: Nervous System Infection Except Viral Meningitis. The
RWP for an inlier case is the CHAMPUS weight of 2.9769. (DRG statistics
shown are from FY 1996).
c. The DoD adjusted standardized amount to be charged is $4,372
(i.e., the third party rate as shown in the table).
d. DoD cost to be recovered at a nonteaching hospital with area
wage index of 1.0 is the RWP factor (2.9769) in 3.b., above, multiplied
by the amount ($4,372) in 3.c., above.
e. Cost to be recovered is $13,015.

Figure 1.--Third Party Billing Examples
----------------------------------------------------------------------------------------------------------------
Arithmetic Geometric Short stay Long stay
DRG No. DRG description DRG weight mean LOS mean LOS threshold threshold
----------------------------------------------------------------------------------------------------------------
020.............. Nervous System 2.9769 11.2 7.8 1 30
Infection Except Viral
Meningitis.
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Area wage IME
Hospital Location rate index adjustment Group ASA Applied ASA
----------------------------------------------------------------------------------------------------------------
Nonteaching Hospital.............. Large Urban......... 1.0 1.0 $4,372.00 $4,372.00
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Relative weighted product TPC
Patient Length of stay Days above -------------------------------------------------------
threshold Inlier * Outlier ** Total Amount ***
----------------------------------------------------------------------------------------------------------------
#1................. 7 days............... 0 2.9769 0.0000 2.9769 $13,015
#2................. 21 days.............. 0 2.9769 0.0000 2.9769 13,015
#3................. 35 days.............. 5 2.9769 0.6297 3.6066 15,768
----------------------------------------------------------------------------------------------------------------
*DRG Weight
**Outlier calculation = 33 percent of per diem weight' number of outlier days = .33 (DRG Weight/Geometric Mean
LOS)' (Patient LOS--Long Stay Threshold)
=.33 (2.9769/7.8) ' (35-30)
=.33 (.38165)' 5 (take out to five decimal places)
=.12594' 5 (take out to five decimal places)
=.6297 (take out to four decimal places)
*** Applied ASA' Total RWP

II. Outpatient Rates ^{1 2} Per Visit

----------------------------------------------------------------------------------------------------------------
International Interagency
Military and other
MEPRS Code \4\ Clinical service Education & Federal agency Other (Full/
Training sponsored Third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
A. Medical Care
----------------------------------------------------------------------------------------------------------------
BAA........................... Internal Medicine............... $105.00 $195.00 $208.00
BAB........................... Allergy......................... 39.00 73.00 78.00
BAC........................... Cardiology...................... 81.00 150.00 160.00
BAE........................... Diabetic........................ 44.00 82.00 87.00
BAF........................... Endocrinology (Metabolism)...... 85.00 158.00 168.00
BAG........................... Gastroenterology................ 110.00 203.00 216.00
BAH........................... Hematology...................... 145.00 269.00 287.00
BAI........................... Hypertension.................... 81.00 149.00 159.00
BAJ........................... Nephrology...................... 171.00 317.00 338.00
BAK........................... Neurology....................... 109.00 202.00 215.00
BAL........................... Outpatient Nutrition............ 34.00 63.00 67.00
BAM........................... Oncology........................ 114.00 211.00 225.00
BAN........................... Pulmonary Disease............... 141.00 260.00 278.00
BAO........................... Rheumatology.................... 84.00 156.00 166.00
BAP........................... Dermatology..................... 63.00 117.00 124.00
BAQ........................... Infectious Disease.............. 141.00 260.00 278.00
BAR........................... Physical Medicine............... 78.00 145.00 155.00
BAS........................... Radiation Therapy............... 72.00 132.00 141.00
BAZ........................... Medical Care Not Elsewhere 84.00 156.00 166.00
Classified (NEC).
----------------------------------------------------------------------------------------------------------------
B. Surgical Care
----------------------------------------------------------------------------------------------------------------
BBA........................... General Surgery................. 119.00 220.00 235.00
BBB........................... Cardiovascular and Thoracic 110.00 203.00 216.00
Surgery.
BBC........................... Neurosurgery.................... 137.00 253.00 270.00
BBD........................... Ophthalmology................... 84.00 155.00 166.00
BBE........................... Organ Transplant................ 191.00 353.00 376.00
BBF........................... Otolaryngology.................. 88.00 162.00 173.00
BBG........................... Plastic Surgery................. 100.00 184.00 196.00
BBH........................... Proctology...................... 67.00 124.00 132.00

[[Page 54134]]

BBI........................... Urology......................... 101.00 187.00 199.00
BBJ........................... Pediatric Surgery............... 89.00 164.00 175.00
BBZ........................... Surgical Care NEC............... 65.00 120.00 127.00
----------------------------------------------------------------------------------------------------------------
C. Obstetrical and Gynecological (OB-GYN) Care
----------------------------------------------------------------------------------------------------------------
BCA........................... Family Planning................. 45.00 83.00 89.00
BCB........................... Gynecology...................... 74.00 136.00 146.00
BCC........................... Obstetrics...................... 68.00 126.00 135.00
BCZ........................... OB-GYN Care NEC................. 112.00 207.00 221.00D
----------------------------------------------------------------------------------------------------------------
D. Pediatric Care
----------------------------------------------------------------------------------------------------------------
BDA........................... Pediatric....................... 54.00 100.00 106.00
BDB........................... Adolescent...................... 55.00 101.00 108.00
BDC........................... Well Baby....................... 36.00 66.00 70.00
BDZ........................... Pediatric Care NEC.............. 64.00 119.00 126.00
----------------------------------------------------------------------------------------------------------------
E. Orthopaedic Care
----------------------------------------------------------------------------------------------------------------
BEA........................... Orthopaedic..................... 83.00 153.00 164.00
BEB........................... Cast............................ 45.00 82.00 88.00
BEC........................... Hand Surgery.................... 38.00 70.00 75.00
BEE........................... Orthotic Laboratory............. 59.00 110.00 117.00
BEF........................... Podiatry........................ 49.00 91.00 97.00
BEZ........................... Chiropractic.................... 21.00 38.00 40.00
----------------------------------------------------------------------------------------------------------------
F. Psychiatric and/or Mental Health Care
----------------------------------------------------------------------------------------------------------------
BFA........................... Psychiatry...................... 97.00 179.00 191.00
BFB........................... Psychology...................... 71.00 132.00 141.00
BFC........................... Child Guidance.................. 59.00 109.00 117.00
BFD........................... Mental Health................... 80.00 147.00 157.00
BFE........................... Social Work..................... 80.00 149.00 159.00
BFF........................... Substance Abuse................. 62.00 115.00 123.00
----------------------------------------------------------------------------------------------------------------
G. Family Practice/Primary Medical Care
----------------------------------------------------------------------------------------------------------------
BGA........................... Family Practice................. 67.00 124.00 132.00
BHA........................... Primary Care.................... 64.00 118.00 126.00
BHB........................... Medical Examination............. 59.00 109.00 117.00
BHC........................... Optometry....................... 42.00 77.00 82.00
BHD........................... Audiology....................... 30.00 55.00 58.00
BHE........................... Speech Pathology................ 81.00 149.00 159.00
BHF........................... Community Health................ 41.00 75.00 80.00
BHG........................... Occupational Health............. 59.00 108.00 115.00
BHH........................... TRICARE Outpatient.............. 42.00 78.00 83.00
BHI........................... Immediate Care.................. 82.00 152.00 162.00
BHZ........................... Primary Care NEC................ 43.00 79.00 84.00
----------------------------------------------------------------------------------------------------------------
H. Emergency Medical Care
----------------------------------------------------------------------------------------------------------------
BIA........................... Emergency Medical............... 107.00 198.00 211.00
----------------------------------------------------------------------------------------------------------------
I. Flight Medical Care
----------------------------------------------------------------------------------------------------------------
BJA........................... Flight Medicine................. 85.00 157.00 167.00
----------------------------------------------------------------------------------------------------------------
J. Underseas Medical Care
----------------------------------------------------------------------------------------------------------------
BKA........................... Underseas Medicine.............. 32.00 58.00 62.00
----------------------------------------------------------------------------------------------------------------
K. Rehabilitative Services
----------------------------------------------------------------------------------------------------------------
BLA........................... Physical Therapy................ 29.00 54.00 57.00
BLB........................... Occupational Therapy............ 53.00 98.00 104.00
----------------------------------------------------------------------------------------------------------------

[[Page 54135]]

III. Other Rates and Charges \1\ \2\ Per Visit

E. Reimbursement Rates For Drugs Requested By Outside Providers \7\
The FY98 drug reimbursement rates for drugs are for prescriptions
requested by outside providers and obtained at a Military Treatment
Facility. The rates are established based on the cost of the particular
drugs provided. Final rule of 32 CFR part 220, estimated to be
published October 1, 1997, will eliminate the high cost ancillary
services' dollar threshold and the associated term ``high cost
ancillary service.'' In anticipation of that change, the phrase ``high
cost ancillary service'' has been replaced with the phrase ``ancillary
services requested by an outside provider.'' The list of drug
reimbursement rates is too large to include here. These rates are
available on request from OASD (Health Affairs)--see Tab N for the
point of contact.
F. Reimbursement Rates for Ancillary Services Requested By Outside
Providers \8\
Final rule of 32 CFR part 220, estimated to be published October 1,
1997, will eliminate the high cost ancillary services' dollar threshold
and the associated term ``high cost ancillary service.'' In
anticipation of that change, the phrase ``high cost ancillary service''
has been replaced with the phrase ``ancillary services requested by an
outside provider.'' The list of FY98 rates for ancillary services
requested by outside providers and obtained at a Military Treatment
Facility is too large to include here. These rates are available on
request from OASD(Health Affairs)--see Tab N for the point of contact.
G. Elective Cosmetic Surgery Procedures and Rates

----------------------------------------------------------------------------------------------------------------
International Current Procedural
Cosmetic surgery procedure Classification Terminology (CPT) FY98 charge \10\ Amount of
Diseases (ICD-9) \9\ charge
----------------------------------------------------------------------------------------------------------------
Mammaplasty.................... 85.50, 85.32, 19325, 19324, Inpatient Surgical (^{a ^{b ^{c)
85.31. 19318. Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Mastopexy...................... 85.60............. 19316............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Facial Rhytidectomy............ 86.82, 86.22...... 15824............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Blepharoplasty................. 08.70, 08.44...... 15820, 15821, Inpatient Surgical (^{a ^{b ^{c)
15822, 15823. Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Mentoplasty (Augmentation 76.68, 76.67...... 21208, 21209...... Inpatient Surgical (^{a ^{b ^{c)
Reduction). Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Abdominoplasty................. 86.83............. 15831............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Lipectomy suction per region 86.83............. 15876, 15877, Inpatient Surgical (^{a ^{b ^{c)
\11\. 15878, 15879. Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Rhinoplasty.................... 21.87, 21.86...... 30400, 30410...... Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Scar Revisions beyond CHAMPUS.. 86.84............. 1578__............ Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Mandibular or Maxillary 76.41............. 21194............. Inpatient Surgical (^{a ^{b ^{c)
Repositioning. Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Minor Skin Lesions \12\........ 86.30............. 1578__............ Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Dermabrasion................... 86.25............. 15780............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Hair Restoration............... 86.64............. 15775............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Removing Tattoos............... 86.25............. 15780............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Chemical Peel.................. 86.24............. 15790............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Arm/Thigh Dermolipectomy....... 86.83............. 1583__............ Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
Brow Lift...................... 86.3.............. 15839............. Inpatient Surgical (^{a ^{b ^{c)
Care Per Diem or APV
or applicable
Outpatient Clinic
Rate.
----------------------------------------------------------------------------------------------------------------

[[Page 54136]]

H. Dental Rate \13\ Per Procedure

----------------------------------------------------------------------------------------------------------------
International Interagency
military and other
MEPRS code \4\ Clinical service education and federal agency Other (Full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
oDental Services................ $35.00 $101.00 $106.00
ADA code and DoD established
weight.
----------------------------------------------------------------------------------------------------------------

I. Ambulance Rate \14\ Per Visit

----------------------------------------------------------------------------------------------------------------
International nteragency and
military other federal
MEPRS code \4\ Clinical service education and agency Other (Full/
training sponsored Third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
FEA........................... Ambulance....................... $32.00 $60.00 $64.00
----------------------------------------------------------------------------------------------------------------

J. Laboratory and Radiology Services Requested by an Outside Provider
\8\ Per Procedure

----------------------------------------------------------------------------------------------------------------
International nteragency &
military other federal
MEPRS code \4\ Clinical service education & agency Other (full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
Laboratory procedures requested $9.00 $13.00 $14.00
by an outside provider CPT-4
Weight Multiplier.
Radiology procedures requested 23.00 35.00 37.00
by an outside provider CPT-4
Weight Multiplier.
----------------------------------------------------------------------------------------------------------------

K. AirEvac Rate \15\ Per Visit

----------------------------------------------------------------------------------------------------------------
International Interagency
military and other
MEPRS code \4\ Clinical service education and federal agency Other (Full/
training sponsored third party)
(IMET) patients
----------------------------------------------------------------------------------------------------------------
AirEvac Services--Ambulatory.... $113.00 $209.00 $223.00
AirEvac Services--Litter........ 323.00 598.00 638.00
----------------------------------------------------------------------------------------------------------------

Notes on Cosmetic Surgery Charges

^a Per diem charges for inpatient surgical care
services are listed in section I.B. (See notes 9 through 11, below,
for further details on reimbursable rates.)
^b Charges for ambulatory procedure visits (formerly
same day surgery) are listed in section III.C. (See notes 9 through
11, below, for further details on reimbursable rates.) The APV rate
is used if the elective cosmetic surgery is performed in an
ambulatory procedure unit (APU).
^c Charges for outpatient clinic visits are listed in
section II.A-K. The outpatient clinic rate is not used for services
provided in an APU. The APV rate should be used in these cases.

Notes on Reimbursable Rates

¹ Percentages can be applied when preparing bills for
both inpatient and outpatient services. Pursuant to the provisions
of 10 U.S.C. 1095, the inpatient Diagnosis Related Groups and
inpatient per diem percentages are 96 percent hospital and 4 percent
professional charges. The outpatient per visit percentages are 88
percent outpatient services and 12 percent professional charges.
² DoD civilian employees located in overseas areas
shall be rendered a bill when services are performed. Payment is due
60 days from the date of the bill.
³ The cost per DRG (Diagnosis Related Group) is based
on the inpatient full reimbursement rate per hospital discharge,
weighted to reflect the intensity of the principal and secondary
diagnoses, surgical procedures, and patient demographics involved.
The adjusted standardized amounts (ASA) per Relative Weighted
Product (RWP) for use in the direct care system is comparable to
procedures used by the Health Care Financing Administration (HCFA)
and the Civilian Health and Medical Program for the Uniformed
Services (CHAMPUS). These expenses include all direct care expenses
associated with direct patient care. The average cost per RWP for
large urban, other urban/rural, and overseas will be published
annually as an adjusted standardized amount (ASA) and will include
the cost of inpatient professional services. The DRG rates will
apply to reimbursement from all sources, not just third party
payers.
⁴ The Medical Expense and Performance Reporting
System (MEPRS) code is a three digit code which defines the summary
account and the subaccount within a functional category in the DoD
medical system. MEPRS codes are used to ensure that consistent
expense and operating performance data is reported in the DoD
military medical system. An example of the MEPRS hierarchical
arrangement follows: Outpatient Care (Functional Category), B (MEPRS
Code), Medical Care (Summary Account), BA (MEPRS Code), Internal
Medicine (Subaccount), BAA (MEPRS Code).
⁵ Hyperbaric services charges shall be based on hours
of service in 15 minute increments. The rates listed in section
III.B. are for 60 minutes or 1 hour of service. Providers shall
calculate the charges based on the number of hours (and/or fractions
of an hour) of service. Fractions of an hour shall be rounded to the
next 15 minute increment (e.g., 31 minutes shall be charged as 45
minutes).
⁶ Ambulatory Procedure Visit (APV) is defined in DOD
Instruction 6025.8, September 23, 1996, as immediate (day of
procedure) pre-procedure and immediate post-procedure care requiring
an unusual degree of intensity and provided in an ambulatory
procedure

[[Page 54137]]

unit (APU). Care is required in the facility for less than 24 hours.
This rate is also used for elective cosmetic surgery performed in an
APU.
⁷ Prescription services requested by outside
providers (physicians, dentists, etc.) are relevant to the Third
Party Collection Program. Third party payers (such as insurance
companies) shall be billed for prescription services when
beneficiaries who have medical insurance obtain medications from a
Military Treatment Facility (MTF) that are prescribed by providers
external to the MTF. Eligible beneficiaries (family members or
retirees with medical insurance) are not personally liable for this
cost and shall not be billed by the MTF. Medical Services Account
(MSA) patients, who are not beneficiaries as defined in 10 U.S.C.
1074 and 1076, are charged at the ``Other'' rate if they are seen by
an outside provider and come to the MTF for prescription services.
The standard cost of medications ordered by an outside provider
includes the cost of the drugs plus a dispensing fee per
prescription. The prescription cost is calculated by multiplying the
number of units (tablets, capsules, etc.) by the unit cost and
adding a $5.00 dispensing fee per prescription. Final rule of 32 CFR
part 220, estimated to be published October 1, 1997, will eliminate
the high cost ancillary services' dollar threshold (by changing it
from $25 to $0) and the associated term ``high cost ancillary
service.'' In anticipation of that change, the phrase ``high cost
ancillary service'' has been replaced with the phrase ``ancillary
services requested by an outside provider.'' The elimination of the
threshold ipso facto eliminates the bundling of costs whereby a
patient was billed if the total ancillary services costs in a day
(defined as 0001 hours to 2400 hours) exceeded $25.00.
⁸ Charges for ancillary services requested by an
outside provider (physicians, dentists, etc.) are relevant to the
Third Party Collection Program. Third party payers (such as
insurance companies) shall be billed for ancillary services when
beneficiaries who have medical insurance obtain services from the
MTF that are prescribed by providers external to the MTF. Laboratory
and Radiology procedure costs are calculated using the Physicians'
Current Procedural Terminology (CPT)-4 Report weight multiplied by
either the laboratory or radiology multiplier (section III.J).
Eligible beneficiaries (family members or retirees with medical
insurance) are not personally liable for this cost and shall not be
billed by the MTF. MSA patients, who are not beneficiaries as
defined by 10 U.S.C. 1074 and 1076, are charged at the ``Other''
rate if they are seen by an outside provider and come to the MTF for
services. Final rule of 32 CFR Part 220, estimated to be published
October 1, 1997, will eliminate the high cost ancillary services'
dollar threshold (by changing it from $25 to $0) and the associated
term ``high cost ancillary service.'' In anticipation of that
change, the phrase ``high cost ancillary service'' has been replaced
with the phrase ``ancillary services requested by an outside
provider.'' The elimination of the threshold ipso facto eliminates
the bundling of costs whereby a patient was billed if the total
ancillary services costs in a day (defined as 0001 hours to 2400
hours) exceeded $25.00.
⁹ The attending physician is to complete the CPT-4
code to indicate the appropriate procedure followed during cosmetic
surgery. The appropriate rate will be applied depending on the
treatment modality of the patient: Ambulatory procedure visit,
outpatient clinic visit or inpatient surgical care services.
¹⁰ Family members of active duty personnel, retirees
and their family members, and survivors shall be charged elective
cosmetic surgery rates. Elective cosmetic surgery procedure
information is contained in Section III G. The patient shall be
charged the rate as specified in the FY98 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
inpatient per diem surgical care services in section I.B.,
ambulatory procedure visits as contained in section III.C, or the
appropriate outpatient clinic rate in section II A-K. The patient is
responsible for the cost of the implant(s) and the prescribed
cosmetic surgery rate. NOTE: The implants and procedures used for
the augmentation mammaplasty are in compliance with Federal Drug
Administration guidelines.
¹¹ Each regional lipectomy shall carry a separate
charge. Regions include head and neck, abdomen, flanks, and hips.
¹² These procedures are inclusive in the minor skin
lesions. However, CHAMPUS separates them as noted here. All charges
shall be for the entire treatment, regardless of the number of
visits required.
¹³ Dental service rates are based on a dental rate
multiplier times the American Dental Association (ADA) code and the
DoD established weight for that code.
¹⁴ Ambulance charges shall be based on hours of
service in 15 minute increments. The rates listed in section III.I
are for 60 minutes or 1 hour of service. Providers shall calculate
the charges based on the number of hours (and/or fractions of an
hour) that the ambulance is logged out on a patient run. Fractions
of an hour shall be rounded to the next 15 minute increment (e.g.,
31 minutes shall be charged as 45 minutes).
¹⁵ Air in-flight medical care reimbursement charges
are determined by the status of the patient (ambulatory or litter)
and are per patient. The charges are billed only by the Air Force
Global Patient Movement Requirement Center (GFMRC).

2. Department of Health and Human Services

For the Department of Health and Human Services, Indian Health
Service, effective October 1, 1997 and thereafter:

Hospital Care Inpatient Day

General Medical Care............... Alaska.................... $1,702
Rest of the United States. 1,049

Outpatient Medical Treatment

Outpatient Visit................... Alaska.................... 340
Rest of the United States. 209

3. Department of Veterans Affairs

For the Department of Veterans Affairs, effective October 1, 1997
and thereafter:

------------------------------------------------------------------------
Tortiously Interagency
liable rates rates
------------------------------------------------------------------------
Hospital Care, Rates Per Inpatient Day
------------------------------------------------------------------------
General Medicine:
Total............................... $1208 $1098
Physician....................... 145 ..............
Ancillary....................... 315 ..............
Nursing, Room, and Board........ 748 ..............
Neurology:
Total............................... 1154 1042
Physician....................... 169 ..............
Ancillary....................... 305 ..............

[[Page 54138]]

Nursing, Room, and Board........ 680 ..............
Rehabilitation Medicine:
Total................................. 808 729
Physician....................... 92 ..............
Ancillary....................... 247 ..............
Nursing, Room, and Board........ 469 ..............
Blind Rehabilitation:
Total................................. 957 873
Physician....................... 77 ..............
Ancillary....................... 475 ..............
Nursing, Room, and Board........ 405 ..............
Spinal Cord Injury:
Total................................. 886 801
Physician....................... 110 ..............
Ancillary....................... 223 ..............
Nursing, Room, and Board........ 553 ..............
Surgery:
Total............................... 2079 1904
Physician....................... 229 ..............
Ancillary....................... 631 ..............
Nursing, Room, and Board........ 1219 ..............
General Psychiatry:
Total............................... 557 518
Physician....................... 54 ..............
Ancillary....................... 91 ..............
Nursing, Room, and Board........ 432 ..............
Substance Abuse (Alcohol and Drug
Treatment):
Total............................... 333 300
Physician....................... 32 ..............
Ancillary....................... 77 ..............
Nursing, Room, and Board........ 224 ..............
Intermediate Medicine:
Total............................... 396 356
Physician....................... 19 ..............
Ancillary....................... 58 ..............
Nursing, Room, and Board........ 319 ..............
------------------------------------------------------------------------
Nursing Home Care, Rates Per Day
------------------------------------------------------------------------
Nursing Home Care:
Total............................... 299 270
Physician....................... 9 ..............
Ancillary....................... 40 ..............
Nursing Room, and Board......... 250 ..............
------------------------------------------------------------------------
Outpatient Medical and Dental Treatment
------------------------------------------------------------------------
Outpatient Visit:
Total............................... 229 211
Emergency Dental........................ 143 127
Outpatient Visit Prescription Filled.... 25 25
------------------------------------------------------------------------

For the period beginning October 1, 1997, the rates prescribed
herein superseded those established by the Director of the Office of
Management and Budget, October 31, 1996 (61 FR 56360).
Franklin D. Raines,
Director, Office of Management and Budget.
[FR Doc. 97-27629 Filed 10-16-97; 8:45 am]
BILLING CODE 3110-01-P}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}