[Federal Register Volume 64, Number 210 (Monday, November 1, 1999)]
[Notices]
[Pages 58862-58870]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-28115]


=======================================================================
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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 FY 2000 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, 1999. Pharmacy rates are updated on an as-needed basis.

2. Health and Human Services

    The development of FY 2000 tortiously liable rates for Indian 
Health Service health facilities incorporate a refinement in the method 
used in the development of the FY 1999 rates. This year the Department 
has elected to use Medicare cost reports to develop the FY 2000 
tortiously liable rates.
    The obligations for the Indian Health Service hospitals 
participating in the cost report project were identified and combined 
with applicable obligations for area offices costs and headquarters 
costs. The hospital obligations were summarized for each major cost 
center providing medical services and distributed between inpatient and 
outpatient. Total inpatient costs and outpatient costs were then 
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 costs were incorporated to conform 
to requirements set forth in OMB Circular A-25.
    In addition, the obligations for each cost center include 
obligations from certain other accounts, such as Medicare and Medicaid 
collections and Contract Health fund, that were used to support direct 
program operations. Obligations were excluded for certain cost centers 
that primarily support workloads outside of the directly operated 
hospitals or clinics (public health nursing, public health nutrition, 
health education).
    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 the Department's hospital facilities.
    Separate rates per inpatient day and outpatient visit were computed 
for

[[Page 58863]]

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 tortiously liable rates shown will be used to seek recovery for 
VA medical care or services provided or furnished to persons in the 
following situations: tort feasor, humanitarian emergency, VA employee, 
family member, ineligible person, and allied beneficiary.
    The interagency rates shown will 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. When the 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.
    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.

1. Department of Defense

    For the Department of Defense, effective October 1, 1999 and 
thereafter:

Medical and Dental Services

Fiscal Year 2000--Inpatient, Outpatient and Other Rates and Charges
I. Inpatient Rates \1\ \2\

----------------------------------------------------------------------------------------------------------------
                                                                   International    Interagency
                                                                     military        and other
                        Per inpatient day                          education and  Federal agency   Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
A. Burn Center..................................................       $3,080.00       $5,529.00       $5,840.00
B. Surgical Care Services (Cosmetic Surgery)....................        1,411.00        2,533.00        2,675.00
C. All Other Inpatient Services (Based on Diagnosis Related
 Groups (DRG) \3\)
----------------------------------------------------------------------------------------------------------------

1. FY 2000 Direct Care Inpatient Reimbursement Rates

----------------------------------------------------------------------------------------------------------------
                                                                                                   Other (full/
                    Adjusted standard amount                           IMET         Interagency    third party)
----------------------------------------------------------------------------------------------------------------
Large Urban.....................................................       $2,921.00       $5,498.00       $5,775.00
Other Urban/Rural...............................................        3,236.00        6,532.00        6,883.00
Overseas........................................................        3,606.00        8,520.00        8,941.00
----------------------------------------------------------------------------------------------------------------

2. Overview
    The FY 2000 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 non-teaching 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 2.3446. (DRG statistics 
shown are from FY 1998).
    c. The DoD adjusted standardized amount to be charged is $5,775 
(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 (2.3446) in 3.b., above, multiplied 
by the amount ($5,775) in 3.c., above.

[[Page 58864]]

    e. Cost to be recovered is $13,540

                                     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                2.3446           8.1           5.7             1            29
                    Infection Except Viral
                    Meningitis.
----------------------------------------------------------------------------------------------------------------


 
----------------------------------------------------------------------------------------------------------------
                                                            Area wage        IME
             Hospital                     Location         rate index    adjustment     Group ASA    Applied ASA
----------------------------------------------------------------------------------------------------------------
Non-teaching Hospital.............  Large Urban.........          1.0           1.0        $5,775        $5,775
----------------------------------------------------------------------------------------------------------------


 
----------------------------------------------------------------------------------------------------------------
                                                                  Relative weighted product              TPC
      Patient            Length of stay      Days above  -------------------------------------------------------
                                              threshold     Inlier *     Outlier * *      Total     Amount * * *
----------------------------------------------------------------------------------------------------------------
#1.................  7 days...............            0        2.3446           000        2.3446       $13,540
#2.................  21 days..............            0        2.3446           000        2.3446       $13,540
#3.................  35 days..............            6        2.3446        0.8144        3.1590       $18,243
----------------------------------------------------------------------------------------------------------------
* 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 (2.3446/5.7)  x  (35-29)
= .33 (.41133)  x  6 (take out to five decimal places)
= .13574  x  6 (take out to five decimal places)
= .8144 (take out to four decimal places)
*** Applied ASA  x  Total RWP

II. Outpatient Rates 1 2 Per Visit

----------------------------------------------------------------------------------------------------------------
                                                                   International    Interagency
                                                                     military        and other
         MEPRS code 4                   Clinical service           education and  Federal agency   Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                                A. Medical Care
----------------------------------------------------------------------------------------------------------------
BAA...........................  Internal Medicine...............         $104.00         $194.00         $204.00
BAB...........................  Allergy.........................           53.00           99.00          105.00
BAC...........................  Cardiology......................           87.00          163.00          172.00
BAE...........................  Diabetic........................           61.00          114.00          121.00
BAF...........................  Endocrinology (Metabolism)......          102.00          190.00          201.00
BAG...........................  Gastroenterology................          146.00          272.00          287.00
BAH...........................  Hematology......................          179.00          334.00          352.00
BAI...........................  Hypertension....................          106.00          198.00          208.00
BAJ...........................  Nephrology......................          208.00          387.00          409.00
BAK...........................  Neurology.......................          121.00          225.00          238.00
BAL...........................  Outpatient Nutrition............           42.00           79.00           83.00
BAM...........................  Oncology........................          134.00          250.00          264.00
BAN...........................  Pulmonary Disease...............          153.00          285.00          301.00
BAO...........................  Rheumatology....................          101.00          188.00          199.00
BAP...........................  Dermatology.....................           78.00          146.00          154.00
BAQ...........................  Infectious Disease..............          178.00          332.00          350.00
BAR...........................  Physical Medicine...............           83.00          155.00          163.00
BAS...........................  Radiation Therapy...............          128.00          238.00          251.00
BAT...........................  Bone Marrow Transplant..........          115.00          214.00          226.00
BAU...........................  Genetic.........................          367.00          683.00          721.00
----------------------------------------------------------------------------------------------------------------
                                                B. Surgical Care
----------------------------------------------------------------------------------------------------------------
BBA...........................  General Surgery.................          148.00          276.00          291.00
BBB...........................  Cardiovascular and Thoracic               320.00          595.00          628.00
                                 Surgery.
BBC...........................  Neurosurgery....................          173.00          323.00          341.00
BBD...........................  Ophthalmology...................           90.00          168.00          177.00
BBE...........................  Organ Transplant................          399.00          742.00          783.00
BBF...........................  Otolaryngology..................          106.00          197.00          207.00
BBG...........................  Plastic Surgery.................          131.00          244.00          258.00
BBH...........................  Proctology......................           84.00          157.00          165.00

[[Page 58865]]

 
BBI...........................  Urology.........................          112.00          209.00          221.00
BBJ...........................  Pediatric Surgery...............          167.00          311.00          328.00
BBK...........................  Peripheral Vascular.............           78.00          146.00          154.00
  ............................  Surgery.........................
BBL...........................  Pain Management.................           97.00          180.00          190.00
----------------------------------------------------------------------------------------------------------------
                                 C. Obstetrical and Gynecological (OB-GYN) Care
----------------------------------------------------------------------------------------------------------------
BCA...........................  Family Planning.................           57.00          106.00          112.00
BCB...........................  Gynecology......................           89.00          165.00          175.00
BCC...........................  Obstetrics......................           74.00          138.00          146.00
BCD...........................  Breast Cancer Clinic............          184.00          342.00          361.00
----------------------------------------------------------------------------------------------------------------
                                               D. Pediatric Care
----------------------------------------------------------------------------------------------------------------
BDA...........................  Pediatric.......................           62.00          115.00          121.00
BDB...........................  Adolescent......................           65.00          122.00          129.00
BDC...........................  Well Baby.......................           42.00           79.00           83.00
----------------------------------------------------------------------------------------------------------------
                                              E. Orthopaedic Care
----------------------------------------------------------------------------------------------------------------
BEA...........................  Orthopaedic.....................           93.00          174.00          183.00
BEB...........................  Cast............................           59.00          110.00          117.00
BEC...........................  Hand Surgery....................           69.00          129.00          136.00
BEE...........................  Orthotic Laboratory.............           67.00          125.00          132.00
BEF...........................  Podiatry........................           56.00          105.00          111.00
BEZ...........................  Chiropractic....................           25.00           47.00           50.00
----------------------------------------------------------------------------------------------------------------
                                    F. Psychiatric and/or Mental Health Care
----------------------------------------------------------------------------------------------------------------
BFA...........................  Psychiatry......................          124.00          230.00          243.00
BFB...........................  Psychology......................           93.00          174.00          184.00
BFC...........................  Child Guidance..................           57.00          105.00          111.00
BFD...........................  Mental Health...................          104.00          194.00          204.00
BFE...........................  Social Work.....................          102.00          190.00          200.00
BFF...........................  Substance Abuse.................           99.00          184.00          195.00
----------------------------------------------------------------------------------------------------------------
                                    G. Family Practice/Primary Medical Care
----------------------------------------------------------------------------------------------------------------
BGA...........................  Family Practice.................           74.00          138.00          146.00
BHA...........................  Primary Care....................           77.00          143.00          151.00
BHB...........................  Medical Examination.............           80.00          148.00          156.00
BHC...........................  Optometry.......................           50.00           93.00           98.00
BHD...........................  Audiology.......................           35.00           65.00           69.00
BHE...........................  Speech Pathology................          101.00          188.00          199.00
BHF...........................  Community Health................           66.00          123.00          130.00
BHG...........................  Occupational Health.............           73.00          136.00          143.00
BHH...........................  TRICARE Outpatient..............           56.00          104.00          109.00
BHI...........................  Immediate Care..................          107.00          200.00          211.00
----------------------------------------------------------------------------------------------------------------
                                           H. Emergency Medical Care
----------------------------------------------------------------------------------------------------------------
BIA...........................  Emergency Medical...............          126.00          234.00          247.00
----------------------------------------------------------------------------------------------------------------
                                             I. Flight Medical Care
----------------------------------------------------------------------------------------------------------------
BJA...........................  Flight Medicine.................           88.00          164.00          173.00
----------------------------------------------------------------------------------------------------------------
                                           J. Underseas Medical Care
----------------------------------------------------------------------------------------------------------------
BKA...........................  Underseas Medicine..............           43.00           79.00           84.00
----------------------------------------------------------------------------------------------------------------
                                           K. Rehabilitative Services
----------------------------------------------------------------------------------------------------------------
BLA...........................  Physical Therapy................           41.00           77.00           81.00
BLB...........................  Occupational Therapy............           61.00          114.00          120.00
----------------------------------------------------------------------------------------------------------------


[[Page 58866]]

III. Ambulatory Procedure Visit (APV) 6 Per Visit

----------------------------------------------------------------------------------------------------------------
                                                                   International    Interagency
                                                                     military        and other
         MEPRS code 4                   Clinical service           education and  Federal agency   Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                Medical Care
BB............................  Surgical Care...................          937.00        1,740.00        1,836.00
BD............................  Pediatric Care..................          233.00          430.00          454.00
BE............................  Orthopaedic Care................        1,179.00        2,192.00        2,313.00
                                All other B clinics not included          430.00          797.00          841.00
                                 above (BA, BC, BF, BG, BH, BI,
                                 BJ, BK and BL).
----------------------------------------------------------------------------------------------------------------

IV. Other Rates and Charges 1 2 Per Visit

----------------------------------------------------------------------------------------------------------------
                                                                   International    Interagency
                                                                     military        and other
         MEPRS code 4                   Clinical service           education and  Federal agency   Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
FBI...........................  A. Immunization.................          $16.00          $30.00          $32.00
DGC...........................  B. Hyperbaric Chamber 5.........          153.00          285.00          301.00
                                C. Family Member Rate (formerly            10.85
                                 Military Dependents Rate).
                                D. Reimbursement Rates For Drugs
                                 Requested By Outside Providers
                                 7
----------------------------------------------------------------------------------------------------------------

    The FY 2000 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 based on the DoD-wide average per National 
Drug Code (NDC) number. Final rule 32 CFR Part 220, which has still not 
been published when this package was prepared, 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)--see Tab O 
for the point of contact.
E. Reimbursement Rates for Ancillary Services Requested By Outside 
Providers 8
    Final rule 32 CFR Part 220, which has still not been published when 
this package was prepared, 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 2000 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 O for the 
point of contact.
F. Elective Cosmetic Surgery Procedures and Rates

----------------------------------------------------------------------------------------------------------------
                                    International
   Cosmetic surgery procedure      Classification    Current Procedural     FY 2000 charge 10       Amount of
                                  Diseases (ICD-9)    Terminology (CPT)                               charge
--------------------------------------------------------------9-------------------------------------------------
Mammaplasty--augmentation......  85.50, 85.32,       19325, 19324,       Inpatient Surgical      (a) (b)
                                  85.31.              19318.              Care Per Diem Or APV.
Mastopexy......................  85.60.............  19316.............  Inpatient Surgical      (a b c)
                                                                          Care Per Diem Or APV
                                                                          or applicable
                                                                          Outpatient Clinic
                                                                          Rate.
Facial.........................  86.82.............  15824.............  Inpatient Surgical      (a b)
                                                                          Care Per Diem Or APV.
Rhytidectomy...................  86.22.............    ................    ....................
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....................  76.68.............  21208.............  Inpatient.............  (a)
(Augmentation/Reduction).......  76.67.............  21209.............  Surgical Care Per Diem  (b c)
                                                                          Or APV or applicable
                                                                          Outpatient Clinic
                                                                          Rate.
Abdominoplasty.................  86.83.............    ................  Inpatient Surgical      (a)
                                                                          Care Per Diem.
Lipectomy Suction per region 11  86.83.............  15876, 15877,       Inpatient Surgical      (a b c)
                                                      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.............  ..................  Inpatient Surgical      (a)
 Repositioning.                                                           Care Per Diem.
Dermabrasion...................  ..................  15780.............  APV or applicable       (b c)
                                                                          Outpatient Clinic
                                                                          Rate.
Hair Restoration...............  ..................  15775.............  APV or applicable       (b c)
                                                                          Outpatient Clinic
                                                                          Rate.
Removing Tattoos...............  ..................  15780.............  APV or applicable       (b c)
                                                                          Outpatient Clinic
                                                                          Rate.
Chemical Peel..................  ..................  15790.............  APV or applicable       (b c)
                                                                          Outpatient Clinic
                                                                          Rate.
Arm/Thigh Dermolipectomy.......  86.83.............  15836/15832.......  Inpatient Surgical      (a b)
                                                                          Care Per Diem Or APV.

[[Page 58867]]

 
Refractive surgery.............  ..................  ..................  APV or applicable       (b c)
                                                                          Outpatient Clinic
                                                                          Rate.
Radial Keratotomy..............  ..................  65771
Other Procedure (if applies to   ..................  66999
 laser or other refractive
 surgery).
Otoplasty......................  ..................  69300.............  APV or applicable       (a b c)
                                                                          Outpatient Clinic
                                                                          Rate.
Brow Lift......................  86.3..............  15839.............  Inpatient Surgical      (a b)
                                                                          Care Per Diem Or APV.
----------------------------------------------------------------------------------------------------------------

G. Dental Rate \12\ Per Procedure

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service           education and      agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
Dental Services                   ..............................          $45.00         $109.00         $115.00
                                ADA code and DoD established
                                 weight..
----------------------------------------------------------------------------------------------------------------

H. Ambulance Rate 13 Per Visit

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service           education and      agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
FEA...........................  Ambulance.......................          $62.00         $116.00         $122.00
----------------------------------------------------------------------------------------------------------------

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

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service           education and      agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                Laboratory procedures requested           $13.00          $20.00          $21.00
                                 by an outside provider CPT '99
                                 Weight Multiplier.
                                Radiology procedures requested            $57.00          $86.00          $90.00
                                 by an outside provider CPT '99
                                 Weight Multiplier.
----------------------------------------------------------------------------------------------------------------

J. AirEvac Rate \14\ Per Visit

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service           education and      agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                AirEvac Services--Ambulatory....         $195.00         $364.00         $384.00
                                AirEvac Services--Litter........         $567.00       $1,056.00       $1,114.00
----------------------------------------------------------------------------------------------------------------

K. Observation Rate \15\ Per hour

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service           education and      agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                Observation Services--Hour......          $17.00          $31.00          $32.00
----------------------------------------------------------------------------------------------------------------

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 
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 98 percent hospital and 2 percent 
professional charges. The outpatient per visit percentages are 89 
percent outpatient services and 11 percent professional charges.

[[Page 58868]]

    \2\ DoD civilian employees located in overseas areas shall be 
rendered a bill when services are performed.
    \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 
sub account 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 service 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). An APU is a location 
or organization within an MTF (or freestanding outpatient clinic) 
that is specially equipped, staffed and designated for the purpose 
of providing the intensive level of care associated with APVs. Care 
is required in the facility for less than 24 hours. All expenses and 
workload are assigned to the MTF-established APU associated with the 
referring clinic. The BB, BD and BE APV rates are only to be used by 
clinics that are subaccounts under these summary accounts (see (\4\) 
for an explanation of MEPRS hierarchical arrangement). The All Other 
APV rate is to be used only by those clinics that are not a 
subaccount under BB, BD or BE.
    \7\ Prescription services requested by outside providers (e.g., 
physicians or dentists) that 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 that 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 $6.00 dispensing fee per 
prescription. Final rule 32 CFR Part 220, which has still not been 
published when this package was prepared, 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 which 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 '99) code 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 
only come to the MTF for ancillary services.
    Final rule 32 CFR Part 220, which has still not been published 
when this package was prepared, 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 '99 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 2000 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.)
    \11\ Each regional lipectomy shall carry a separate charge. 
Regions include head and neck, abdomen, flanks, and hips.
    \12\ 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.
    \13\ 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).
    \14\ 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). These 
charges are only for the cost of providing medical care. Flight 
charges are billed by GPMRC separately using the commercial rate 
effective the date of travel plus $1.

[[Page 58869]]

    \15\ Observation Services are billed at the hourly charge. Begin 
counting when the patient is placed in the observation bed and round 
up to the nearest hour. 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 to recover all expenses.

2. Department of Health and Human Services

    For the Department of Health and Human Services, Indian Health 
Service, effective October 1, 1999 and thereafter:

                       Hospital Care Inpatient Day
General Medical Care...............  Alaska....................   $1,925
                                     Rest of the United States.   1,313
                      Outpatient Medical Treatment
Outpatient Visit...................  Alaska....................      308
                                     Rest of the United States.      211
 

3. Department of Veterans Affairs

    Effective October 1, 1999, and thereafter:

------------------------------------------------------------------------
                                            Tortiously      Interagency
                                           liable rates        rates
------------------------------------------------------------------------
                 Hospital Care, Rates Per Inpatient Day
------------------------------------------------------------------------
General Medicine:
    Total...............................           $1610           $1476
        Physician.......................             193
        Ancillary.......................             420
        Nursing, Room, and Board........             997
Neurology:
    Total...............................            1927            1757
        Physician.......................             282
        Ancillary.......................             509
        Nursing, Room, and Board........            1136
Rehabilitation Medicine:
    Total...............................            1065             974
        Physician.......................             121
        Ancillary.......................             325
        Nursing, Room, and Board........             619
Blind Rehabilitation:
    Total...............................            1009             928
        Physician.......................              81
        Ancillary.......................             501
        Nursing, Room, and Board........             427
Spinal Cord Injury:
    Total...............................             970             885
        Physician.......................             120
        Ancillary.......................             244
        Nursing, Room, and Board........             606
Surgery:
    Total...............................            3023            2788
        Physician.......................             333
        Ancillary.......................             917
        Nursing, Room, and Board........            1773
General Psychiatry:
    Total...............................             640             577
        Physician.......................              60
        Ancillary.......................             101
        Nursing, Room, and Board........             479
Substance Abuse (Alcohol and Drug
 Treatment):
    Total...............................             339             308
        Physician.......................              32
        Ancillary.......................              78
        Nursing, Room, and Board........             229
Intermediate Medicine:
    Total...............................             491             446
        Physician.......................              24
        Ancillary.......................              72
        Nursing, Room, and Board........             395
------------------------------------------------------------------------
                    Nursing Home Care, Rates Per Day
------------------------------------------------------------------------
Nursing Home Care:
    Total...............................             339             307
        Physician.......................              11
        Ancillary.......................              46
        Nursing, Room, and Board........             282
------------------------------------------------------------------------
 
[[Page 58870]]

 
                Outpatient Medical and Dental Treatment
------------------------------------------------------------------------
Outpatient Visit (other than Emergency               254             236
 Dental)................................
Emergency Dental Outpatient Visit.......             157             140
Prescription Filled.....................              36              35
------------------------------------------------------------------------

    For the period beginning October 1, 1999, the rates prescribed 
herein superseded those established by the Director of the Office of 
Management and Budget October 16, 1998 (61 FR 56360).
Jacob J. Lew,
Director, Office of Management and Budget.
[FR Doc. 99-28115 Filed 10-29-99; 8:45 am]
BILLING CODE 3110-01-P