[Federal Register Volume 63, Number 200 (Friday, October 16, 1998)]
[Notices]
[Pages 55653-55659]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-27813]


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

1. Department of Defense

    The FY 1999 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.E) and 
the rates for Ancillary Services Requested by Outside Providers 
(Section III.F) 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, 1998.

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 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 obligations from certain other accounts, 
such as Medicare and Medicaid collections and Contract Health funds 
that were used to support direct program operations. 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. These obligations are not a 
part of the traditional cost of hospital operations and do not 
contribute 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.

1. Department of Defense

    For the Department of Defense, effective October 1, 1998 and 
thereafter:

[[Page 55654]]

Inpatient, Outpatient and Other Rates and Charge

I. Inpatient Rates \1\ \2\

----------------------------------------------------------------------------------------------------------------
                                                                                    Interagency
                                                                   International     and other         Other
                                                                     military     federal agency     sponsored
                                                                   education per   and training      patients
                                                                   inpatient day      (IMET)
----------------------------------------------------------------------------------------------------------------
A. Burn Center..................................................       $2,538.00       $4,632.00       $4,952.00
B. Surgical Care Services (Cosmetic Surgery)....................        1,236.00        2,255.00        2,411.00
----------------------------------------------------------------------------------------------------------------

C. All Other Inpatient Services (Based on Diagnosis Related Groups 
(DRG) \3\)
1. FY99 Direct Care Inpatient Reimbursement Rates

----------------------------------------------------------------------------------------------------------------
                                                                                                   Other  (full/
                    Adjusted standard amount                           IMET         Interagency    third party)
----------------------------------------------------------------------------------------------------------------
Large Urban.....................................................       $2,429.00       $4,552.00       $4,825.00
Other Urban/Rural...............................................        2,642.00        5,413.00        5,760.00
Overseas........................................................        2,989.00        6,823.00        7,234.00
----------------------------------------------------------------------------------------------------------------

2. Overview
    The FY99 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
    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 1997).
    c. The DoD adjusted standardized amount to be charged is $4,825 
(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 ($4,825) in 3.c., above.
    e. Cost to be recovered is $14,364.

                                     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 Infection       2.9769         11.2          7.8            1           30
                        Except Viral Meningitis.
----------------------------------------------------------------------------------------------------------------


Nonteaching Hospital.............  Large Urban..............          1.0          1.0    $4,825.00    $4,825.00
----------------------------------------------------------------------------------------------------------------


#1.....................  7 days................            0       2.9769       0.0000       2.9769      $14,364
#2.....................  21 days...............            0       2.9769       0.0000       2.9769       14,364
#3.....................  35 days...............            5       2.9769       0.6297       3.6066       17,402
----------------------------------------------------------------------------------------------------------------
*DRG Weight.
**Outlier calculation=33 percent of per diem weight  x  number of outlier days=.33 (DRG Weight/Geometric Mean
  LOS) x (Patient LOS--Long Stay Threshold).
  =.33 (2.9769/7.8) x (35-30).
  =.33 (.38165) x 5 (take out to five decimal places).
  =.12594 x 5 (take out to five decimal places).
  =.6297 (take out to four decimal places).
***Applied ASA x Total RWP.


[[Page 55655]]

II. Outpatient Rates 1 2 Per Visit

----------------------------------------------------------------------------------------------------------------
                                                           International      Interagency &
                                                              military        other federal      Other  (full/
       MEPRS code \4\             Clinical service          education &      agency sponsored     third party)
                                                          training (IMET)        patients
----------------------------------------------------------------------------------------------------------------
                                                 A. Medical Care
----------------------------------------------------------------------------------------------------------------
BAA........................  Internal Medicine.........            $104.00            $186.00            $198.00
BAB........................  Allergy...................              48.00              86.00              92.00
BAC........................  Cardiology................              78.00             140.00             149.00
BAE........................  Diabetic..................              57.00             102.00             108.00
BAF........................  Endocrinology (Metabolism)              90.00             162.00             173.00
BAG........................  Gastroenterology..........             114.00             205.00             219.00
BAH........................  Hematology................             145.00             260.00             277.00
BAI........................  Hypertension..............              89.00             160.00             170.00
BAJ........................  Nephrology................             138.00             245.00             261.00
BAK........................  Neurology.................             112.00             200.00             213.00
BAL........................  Outpatient Nutrition......              33.00              59.00              63.00
BAM........................  Oncology..................             132.00             236.00             251.00
BAN........................  Pulmonary Disease.........             118.00             211.00             225.00
BAO........................  Rheumatology..............              84.00             151.00             160.00
BAP........................  Dermatology...............              68.00             122.00             130.00
BAQ........................  Infectious Disease........             126.00             225.00             240.00
BAR........................  Physical Medicine.........              74.00             133.00             142.00
BAS........................  Radiation Therapy.........              91.00             164.00             174.00
----------------------------------------------------------------------------------------------------------------
                                                B. Surgical Care
----------------------------------------------------------------------------------------------------------------
BBA........................  General Surgery...........             164.00             295.00             314.00
BBB........................  Cardiovascular and                     132.00             237.00             252.00
                              Thoracic Surgery.
BBC........................  Neurosurgery..............             188.00             337.00             359.00
BBD........................  Ophthalmology.............             102.00             183.00             194.00
BBE........................  Organ Transplant..........             239.00             429.00             457.00
BBF........................  Otolaryngology............             124.00             222.00             237.00
BBG........................  Plastic Surgery...........             129.00             231.00             247.00
BBH........................  Proctology................              65.00             117.00             124.00
BBI........................  Urology...................             125.00             224.00             239.00
BBJ........................  Pediatric Surgery.........              91.00             163.00             174.00
----------------------------------------------------------------------------------------------------------------
                                 C. Obstetrical and Gynecological (OB-GYN) Care
----------------------------------------------------------------------------------------------------------------
BCA........................  Family Planning...........              45.00              81.00              87.00
BCB........................  Gynecology................             101.00             181.00             193.00
BCC........................  Obstetrics................              72.00             129.00             137.00
BCD........................  Breast Cancer Clinic......             171.00             307.00             327.00
----------------------------------------------------------------------------------------------------------------
                                                D. Pediatric Care
----------------------------------------------------------------------------------------------------------------
BDA........................  Pediatric.................              63.00             113.00             120.00
BDB........................  Adolescent................              60.00             108.00             115.00
BDC........................  Well Baby.................              40.00              71.00              76.00
----------------------------------------------------------------------------------------------------------------
                                               E. Orthopaedic Care
----------------------------------------------------------------------------------------------------------------
BEA........................  Orthopaedic...............             118.00             212.00             226.00
BEB........................  Cast......................              50.00              90.00              96.00
BEC........................  Hand Surgery..............              61.00             109.00             116.00
BEE........................  Orthotic Laboratory.......              60.00             108.00             115.00
BEF........................  Podiatry..................              67.00             119.00             127.00
BEZ........................  Chiropractic..............              24.00              42.00              45.00
----------------------------------------------------------------------------------------------------------------
                                    F. Psychiatric and/or Mental Health Care
----------------------------------------------------------------------------------------------------------------
BFA........................  Psychiatry................              97.00             174.00             186.00
BFB........................  Psychology................              79.00             141.00             150.00
BFC........................  Child Guidance............              52.00              93.00              99.00
BFD........................  Mental Health.............             105.00             188.00             201.00
BFE........................  Social Work...............              77.00             137.00             146.00
BFF........................  Substance Abuse...........              82.00             147.00             156.00
----------------------------------------------------------------------------------------------------------------
                                     G. Family Practice/Primary Medical Care
----------------------------------------------------------------------------------------------------------------
BGA........................  Family Practice...........              74.00             133.00             141.00
BHA........................  Primary Care..............              75.00             134.00             143.00
BHB........................  Medical Examination.......              66.00             118.00             126.00

[[Page 55656]]

BHC........................  Optometry.................              48.00              86.00              91.00
BHD........................  Audiology.................              27.00              49.00              52.00
BHE........................  Speech Pathology..........              69.00             123.00             131.00
BHF........................  Community Health..........              48.00              87.00              92.00
BHG........................  Occupational Health.......              78.00             141.00             150.00
BHH........................  TRICARE Outpatient........              44.00              79.00              84.00
BHI........................  Immediate Care............             108.00             193.00             206.00
----------------------------------------------------------------------------------------------------------------
                                            H. Emergency Medical Care
----------------------------------------------------------------------------------------------------------------
BIA........................  Emergency Medical.........             114.00             205.00             218.00
----------------------------------------------------------------------------------------------------------------
                                             I. Flight Medical Care
----------------------------------------------------------------------------------------------------------------
BJA........................  Flight Medicine...........             103.00             185.00             197.00
----------------------------------------------------------------------------------------------------------------
                                            J. Underseas Medical Care
----------------------------------------------------------------------------------------------------------------
BKA........................  Underseas Medicine........              35.00              63.00              67.00
----------------------------------------------------------------------------------------------------------------
                                           K. Rehabilitative Services
----------------------------------------------------------------------------------------------------------------
BLA........................  Physical Therapy..........              34.00              60.00              64.00
BLB........................  Occupational Therapy......              48.00              86.00              91.00
----------------------------------------------------------------------------------------------------------------

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

----------------------------------------------------------------------------------------------------------------
                                                           International     Interagency and
                                                              Military        other federal      Other  (full/
       MEPRS Code \4\             Clinical service          Education &      agency sponsored     third party)
                                                          Training (IMET)        patients
----------------------------------------------------------------------------------------------------------------
FBI........................  A. Immunization...........             $13.00             $22.00             $24.00
DGC........................  B. Hyperbaric Chamber \5\.             191.00             343.00             366.00
                             C. Ambulatory Procedure                926.00           1,657.00           1,765.00
                              Visit (APV) \6\.
                             D. Family Member Rate                   10.45  .................  .................
                              (formerly Military
                              Dependents Rate).
----------------------------------------------------------------------------------------------------------------

E. Reimbursement Rates For Drugs Requested By Outside Providers \7\
    The FY 1999 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 32 CFR part 220 eliminates the 
high cost ancillary services' dollar threshold and the associated term 
``high cost ancillary service.'' The phrase ``high cost ancillary 
service'' will be replaced with the phrase ``ancillary services 
requested by an outside provider'' on publication of final rule 32 CFR 
part 220. The list of drug reimbursement rates is too large to include 
here. These rates are available on request from OASD (Health Affairs).
F. Reimbursement Rates for Ancillary Services Requested By Outside 
Providers \8\
    Final rule 32 CFR part 220 eliminates the high cost ancillary 
services' dollar threshold and the associated term ``high cost 
ancillary service.'' The phrase ``high cost ancillary service'' will be 
replaced with the phrase ``ancillary services requested by an outside 
provider'' on publication of final rule 32 CFR part 220. The list of FY 
1999 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).
G. Elective Cosmetic Surgery Procedures and Rates

----------------------------------------------------------------------------------------------------------------
                                    International    Current procedural
   Cosmetic surgery procedure      Classification     terminology (CPT)    FY 1999 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.

[[Page 55657]]

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.............  15785.............  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.............  15785.............  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.............  15839.............  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.
----------------------------------------------------------------------------------------------------------------

H. Dental Rate \13\ Per Procedure

----------------------------------------------------------------------------------------------------------------
                                                           International      Interagency &
                                                              military        other federal      Other  (full/
       MEPRS code \4\             Clinical service          education &      agency sponsored     third party)
                                                          training (IMET)        patients
----------------------------------------------------------------------------------------------------------------
                             Dental Services, ADA code              $56.00            $101.00            $108.00
                              and DoD established
                              weight.
----------------------------------------------------------------------------------------------------------------

I. Ambulance Rate \14\ Per Visit

----------------------------------------------------------------------------------------------------------------
                                                           International      Interagency &
                                                              military        other federal      Other  (full/
       MEPRS code \4\             Clinical service          education &      agency sponsored     third party)
                                                          training (IMET)        patients
----------------------------------------------------------------------------------------------------------------
FEA........................  Ambulance.................             $56.00            $101.00            $107.00
----------------------------------------------------------------------------------------------------------------

J. Ancillary Services Requested by an Outside Provider \8\ Per 
Procedure

----------------------------------------------------------------------------------------------------------------
                                                           International      Interagency &
                                                              military        other federal      Other  (full/
       MEPRS code \4\             Clinical service          education &      agency sponsored     third party)
                                                          training (IMET)        patients
----------------------------------------------------------------------------------------------------------------
                             Laboratory procedures                  $10.00             $17.00             $18.00
                              requested by an outside
                              provider CPT '98 Weight
                              Multiplier.
                             Radiology procedures                    25.00              45.00              48.00
                              requested by an outside
                              provider CPT '98 Weight
                              Multiplier.
                             Cardiology procedures                   17.00              31.00              33.00
                              requested by an outside
                              provider CPT '98 Weight
                              Multiplier.
----------------------------------------------------------------------------------------------------------------

K. AirEvac Rate \15\ Per Visit

----------------------------------------------------------------------------------------------------------------
                                                           International      Interagency &
                                                              military        other federal      Other  (full/
       MEPRS code \4\             Clinical service          education &      agency sponsored     third party)
                                                          training (IMET)        patients
----------------------------------------------------------------------------------------------------------------
                             AirEvac Services--                     $90.00            $161.00            $172.00
                              Ambulatory.
                             AirEvac Services--Litter..             256.00             459.00             489.00
----------------------------------------------------------------------------------------------------------------

Observation Rate \16\ Per Hour

----------------------------------------------------------------------------------------------------------------
                                                           International      Interagency &
                                                              military        other federal      Other  (full/
       MEPRS code \4\             Clinical service          education &      agency sponsored     third party)
                                                          training (IMET)        patients
----------------------------------------------------------------------------------------------------------------
                             Observation Services--Hour             $14.50             $25.83             $27.50
----------------------------------------------------------------------------------------------------------------


[[Page 55658]]

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 
ambulatory procedure visit (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 
Sections 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 89 
percent outpatient services and 11 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 Diagnosis Related Group (DRG) is based on the 
inpatient full reimbursement rate per hospital discharge, weighted 
to reflect the intensity of the principal and secondary diagnoses, 
surgical procedures, and patient demographics involved. The 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:

MEPRS Code

Outpatient Care (Functional Category)  B
Medical Care (Summary Account)  BA
Internal Medicine (Subaccount)  BAA
    \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 is defined in DOD Instruction 
6025.8, ``Ambulatory Procedure Visit (APV),'' dated 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 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 (e.g., 
physicians or dentists) 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 only 
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 (e.g., tablets or 
capsules) by the unit cost and adding a $5.00 dispensing fee per 
prescription. Final rule 32 CFR part 220 eliminates the high cost 
ancillary services' dollar threshold and the associated term ``high 
cost ancillary service.'' The phrase ``high cost ancillary service'' 
will be replaced with the phrase ``ancillary services requested by 
an outside provider'' on publication of final rule 32 CFR part 220. 
The elimination of the threshold also eliminates the need to bundle 
costs whereby a patient is billed if the total cost of ancillary 
services in a day (defined as 0001 hours to 2400 hours) exceeded 
$25.00. The elimination of the threshold is effective as per date 
stated in final rule 32 CFR part 220.
    \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 by multiplying the DoD 
established weight for the Physicians' Current Procedural 
Terminology (CPT `98) code by either the cardiology, 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 only come to the MTF for ancillary services. 
Final rule 32 CFR part 220 eliminates the high cost ancillary 
services' dollar threshold and the associated term ``high cost 
ancillary service.'' The phrase ``high cost ancillary service'' will 
be replaced with the phrase ``ancillary services requested by an 
outside provider'' on publication of final rule 32 CFR part 220. The 
elimination of the threshold also eliminates the need to bundle 
costs whereby a patient is billed if the total cost of ancillary 
services in a day (defined as 0001 hours to 2400 hours) exceeded 
$25.00. The elimination of the threshold is effective as per date 
stated in final rule 32 CFR part 220.
    \9\ The attending physician is to complete the CPT `98 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 FY 1999 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 Sections 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.)

[[Page 55659]]

    \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 appropriate charges are billed only by the Air 
Force Global Patient Movement Requirement Center (GPMRC).
    \16\ Observation Services are billed at either the hourly or 
daily charge. Begin counting when the patient is placed in the 
observation bed, and round to the nearest hour. The daily rate for 
full/third party, for example, would be $660 based on 24 hours of 
service. If a patient status changes to inpatient, the charges for 
observation services are added to the DRG assigned to the case and 
not billed separately. If a patient is released from Observation 
status and is sent to an APV, the charges for Observation services 
are not billed separately, but are added to the APV rate in order to 
recover all expenses.

1. Department of Health and Human Services

    For the Department of Health and Human Services, Indian Health 
Service, effective October 1, 1998 and thereafter:

Hospital Care Inpatient Day

General Medical Care:
    Alaska.................................................       $1,798
    Rest of the United States..............................        1,049

Outpatient Medical Treatment

Outpatient Visit:
    Alaska.................................................         $360
    Rest of the United States..............................          210

    For the period beginning October 1, 1998, the rates prescribed 
herein superseded those established by the Director of the Office of 
Management and Budget October 31, 1997 (61 FR 56360).
Jacob Lew,
Director, Office of Management and Budget.
[FR Doc. 98-27813 Filed 10-15-98; 8:45 am]
BILLING CODE 3110-01-P