[Federal Register Volume 65, Number 237 (Friday, December 8, 2000)]
[Notices]
[Pages 76990-76998]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-31242]


-----------------------------------------------------------------------

DEPARTMENT OF DEFENSE

Office of the Secretary


Medical and Dental Services for Fiscal Year 2001

SUMMARY: Notice is hereby given that on September 30, 2000, the Deputy 
Chief Financial Officer approved the following reimbursement rates for 
inpatient and outpatient medical care to be provided in FY 2001. These 
rates were effective October 1, 2000.
    The FY 2001 Department of Defense (DoD) reimbursement rates for 
inpatient, outpatient, and other services are provided in accordance 
with Title 10, United States Code, section 1095. Due to

[[Page 76991]]

size, the sections containing the Drug Reimbursement Rates (section 
IV.C.) and the rates for Ancillary Services Requested by Outside 
Providers (section IV.D.) are not included in this package. Those rates 
are available from the TRICARE Management Activity's Uniform Business 
Office website: http://www.tricare.osd.mil/ebc/rm/rm_home.html. The 
Office of the Assistant Secretary of Defense (Health Affairs) point of 
contact is MAJ Rose Layman. She can be reached at (703) 681-8910 or DSN 
761-8910. The medical and dental service rates in this package 
(including the rates for ancillary services and other procedures 
requested by outside providers) were effective October 1, 2000. 
Pharmacy rates are updated on an as needed basis.

    Dated: December 1, 2000.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.

Inpatient, Outpatient and Other Rates and Charges

I. Inpatient Rates1 2

 
----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
                        Per inpatient day                           education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
A. Burn Center..................................................       $4,144.00       $5,694.00       $6,016.00
B. Surgical Care Services (Cosmetic Surgery)....................        1,895.00        2,604.00        2,752.00
C. All Other Inpatient Services (Based on Diagnosis Related
 Groups (DRG).\3\
----------------------------------------------------------------------------------------------------------------

1. Average FY 2001 Direct Care Inpatient Reimbursement Rates

----------------------------------------------------------------------------------------------------------------
                                                                                                   Other (full/
                    Adjusted standard amount                           IMET         Ineragency     third party)
----------------------------------------------------------------------------------------------------------------
Large Urban.....................................................       $2,986.00       $5,712.00       $6,002.00
Other Urban/Rural...............................................        3,468.00        6,633.00        7,004.00
Overseas........................................................        3,872.00        9,045.00        9,489.00
----------------------------------------------------------------------------------------------------------------

2. Overview
    The FY 2001 inpatient rates are based on the cost per Diagnosis 
Related Group (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. Each large urban or other urban/rural Military 
Treatment Facility (MTF) providing inpatient care has their own ASA 
rate. The MTF-specific ASA rate is the published ASA rate adjusted for 
area wage differences and indirect medical education (IME) for the 
discharging hospital (see Attachment 1). The MTF-specific ASA rate 
submitted on the claim is the rate that payers will use for 
reimbursement purposes. Overseas MTFs use the rates specified in 
paragraph I.C.1. For providers performing inpatient care at a civilian 
facility for a DoD beneficiary, see note 3. For a more complete 
description of the development of MTF-specific ASAs and how they are 
applied refer to the ASA Primer at: http://www.tricare.osd.mil/org/pae/asa_primer/asa_primer.html.
    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 (Reynolds Army 
Community Hospital) in Other Urban/Rural areas.
    a. The cost to be recovered is the MTF cost for medical services 
provided. 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 2.2244. (DRG statistics 
shown are from FY 1999.)
    c. The MTF-applied ASA rate is $6,831 (Reynolds Army Community 
Hospital's third party rate as shown in Attachment 1).
    d. The MTF cost to be recovered is the RWP factor (2.2244) in 
subparagraph 3.b., above, multiplied by the amount ($6,831) in 
subparagraph 3.c., above.
    e. Cost to be recovered is $15,195.

                                     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         2.2244          8.3          5.8            1           29
                      Except Viral Meningitis.
----------------------------------------------------------------------------------------------------------------


[[Page 76992]]


----------------------------------------------------------------------------------------------------------------
                                                               Area wage       IME                   MTF-applied
              Hospital                       Location          rate index   adjustment   Group ASA       ASA
----------------------------------------------------------------------------------------------------------------
Reynolds Army Community Hospital....  Other Urban/Rural.....        .9156          1.0       $7,004       $6,831
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                                                    Relative weighted product
        Patient              Length of stay       Days above ---------------------------------------  TPC amount
                                                  threshold     Inlier *    Outlier **     Total         ***
----------------------------------------------------------------------------------------------------------------
#1....................  7 days.................            0       2.2244          000       2.2244      $15,195
#2....................  21 days................            0       2.2244          000       2.2244       15,195
#3....................  35 days................            6       2.2244        .7594       2.9838      20,382
----------------------------------------------------------------------------------------------------------------
* 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 (2.2244/5.8) x (35-29).
=.33 (.38352) x 6 (take out to five decimal places).
.12656 x 6 (carry to five decimal places).
.7594 (carry to four decimal places).
*** MTF-Applied ASA x Total RWP.

II. Outpatient Rates--Per Visit \1\ \2\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                                 A. Medical Care
----------------------------------------------------------------------------------------------------------------
BAA...........................  Internal Medicine...............         $147.00         $204.00         $216.00
BAB...........................  Allergy.........................           80.00          111.00          117.00
BAC...........................  Cardiology......................          129.00          180.00          190.00
BAE...........................  Diabetic........................          105.00          146.00          154.00
BAF...........................  Endocrinology (Metabolism)......          151.00          210.00          222.00
BAG...........................  Gastroenterology................          183.00          255.00          269.00
BAH...........................  Hematology......................          286.00          398.00          420.00
BAI...........................  Hypertension....................          216.00          301.00          318.00
BAJ...........................  Nephrology......................          221.00          307.00          324.00
BAK...........................  Neurology.......................          165.00          229.00          242.00
BAL...........................  Outpatient Nutrition............           69.00           96.00          101.00
BAM...........................  Oncology........................          201.00          280.00          295.00
BAN...........................  Pulmonary Disease...............          186.00          259.00          273.00
BAO...........................  Rheumatology....................          139.00          194.00          205.00
BAP...........................  Dermatology.....................          115.00          160.00          169.00
BAQ...........................  Infectious Disease..............          181.00          252.00          266.00
BAR...........................  Physical Medicine...............          115.00          160.00          169.00
BAS...........................  Radiation Therapy...............          169.00          235.00          248.00
BAT...........................  Bone Marrow Transplant..........          190.00          264.00          279.00
BAU...........................  Genetic.........................          330.00          460.00          485.00
BAV...........................  Hyperbaric......................          344.00          480.00          506.00
----------------------------------------------------------------------------------------------------------------
                                                B. Surgical Care
----------------------------------------------------------------------------------------------------------------
BBA...........................  General Surgery.................          215.00          299.00          316.00
BBB...........................  Cardiovascular and Thoracic               419.00          584.00          616.00
                                 Surgery.
BBC...........................  Neurosurgery....................          249.00          347.00          366.00
BBD...........................  Ophthalmology...................          130.00          181.00          191.00
BBE...........................  Organ Transplant................        1,106.00        1,541.00        1,625.00
BBF...........................  Otolaryngology..................          149.00          207.00          219.00
BBG...........................  Plastic Surgery.................          168.00          235.00          247.00
BBH...........................  Proctology......................          125.00          174.00          184.00
BBI...........................  Urology.........................          164.00          228.00          240.00
BBJ...........................  Pediatric Surgery...............           89.00          125.00          131.00
BBK...........................  Peripheral Vascular Surgery.....           98.00          137.00          145.00
BBL...........................  Pain Management.................          138.00          193.00          203.00
BBM...........................  Vascular and Interventional               493.00          687.00          724.00
                                 Radiology.
----------------------------------------------------------------------------------------------------------------
                                 C. Obstetrical and Gynecological (OB-GYN) Care
----------------------------------------------------------------------------------------------------------------
BCA...........................  Family Planning.................           76.00          106.00          111.00
BCB...........................  Gynecology......................          127.00          177.00          187.00
BCC...........................  Obstetrics......................          104.00          144.00          152.00
BCD...........................  Breast Cancer Clinic............          240.00          334.00          352.00
----------------------------------------------------------------------------------------------------------------

[[Page 76993]]

 
                                                D. Pediatric Care
----------------------------------------------------------------------------------------------------------------
BDA...........................  Pediatric.......................           92.00          128.00          134.00
BDB...........................  Adolescent......................           83.00          115.00          121.00
BDC...........................  Well Baby.......................           63.00           87.00           92.00
----------------------------------------------------------------------------------------------------------------
                                               E. Orthopaedic Care
----------------------------------------------------------------------------------------------------------------
BEA...........................  Orthopaedic.....................          143.00          200.00          211.00
BEB...........................  Cast............................           89.00          123.00          130.00
BEC...........................  Hand Surgery....................           76.00          106.00          112.00
BEE...........................  Orthotic Laboratory.............           93.00          130.00          137.00
BEF...........................  Podiatry........................           80.00          112.00          118.00
BEZ...........................  Chiropractic....................           38.00           53.00           55.00
----------------------------------------------------------------------------------------------------------------
                                    F. Psychiatric and/or Mental Health Care
----------------------------------------------------------------------------------------------------------------
BFA...........................  Psychiatry......................          165.00          230.00          242.00
BFB...........................  Psychology......................          115.00          160.00          169.00
BFC...........................  Child Guidance..................           92.00          128.00          135.00
BFD...........................  Mental Health...................          148.00          206.00          217.00
BFE...........................  Social Work.....................          147.00          205.00          217.00
BFF...........................  Substance Abuse.................          141.00          197.00          208.00
----------------------------------------------------------------------------------------------------------------
                                     G. Family Practice/Primary Medical Care
----------------------------------------------------------------------------------------------------------------
BGA...........................  Family Practice.................          107.00          149.00          157.00
BHA...........................  Primary Care....................          109.00          151.00          160.00
BHB...........................  Medical Examination.............          111.00          155.00          163.00
BHC...........................  Optometry.......................           72.00          100.00          105.00
BHD...........................  Audiology.......................           52.00           73.00           77.00
BHE...........................  Speech Pathology................          122.00          170.00          180.00
BHF...........................  Community Health................           85.00          118.00          125.00
BHG...........................  Occupational Health.............          108.00          151.00          159.00
BHH...........................  TRICARE Outpatient..............           74.00          104.00          109.00
BHI...........................  Immediate Care..................          161.00          225.00          237.00
----------------------------------------------------------------------------------------------------------------
                                            H. Emergency Medical Care
----------------------------------------------------------------------------------------------------------------
BIA...........................  Emergency Medical...............          173.00          242.00          255.00
----------------------------------------------------------------------------------------------------------------
                                             I. Flight Medical Care
----------------------------------------------------------------------------------------------------------------
BJA...........................  Flight Medicine.................          124.00          173.00          182.00
----------------------------------------------------------------------------------------------------------------
                                            J. Underseas Medical Care
----------------------------------------------------------------------------------------------------------------
BKA...........................  Underseas Medicine..............           77.00          108.00          114.00
----------------------------------------------------------------------------------------------------------------
                                           K. Rehabilitative Services
----------------------------------------------------------------------------------------------------------------
BLA...........................  Physical Therapy................           56.00           79.00           83.00
BLB...........................  Occupational Therapy............           75.00          104.00          110.00
----------------------------------------------------------------------------------------------------------------

III. Ambulatory Procedure Visit (APV)--Per Visit \5\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
         MEPRS code \4\                  Clinical service           education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                                  Medical Care
----------------------------------------------------------------------------------------------------------------
BB..............................  Surgical Care.................       $1,313.00       $1,829.00       $1,929.00
BE..............................  Orthopaedic Care..............        1,664.00        2,319.00        2,446.00
All Other.......................  B clinics other than BB and             378.00          527.00          556.00
                                   BE, to include those B
                                   clinics where:
                                  1. There is an APU established
                                   within DoD guidelines AND
                                   2. There is a rate
                                   established for that clinic
                                   in section II.
                                  Some B clinics, such as BF,
                                   BI, BJ and BL, perform the
                                   type of services where the
                                   establishment of an APU would
                                   not be within appropriate
                                   clinical guidelines.
----------------------------------------------------------------------------------------------------------------


[[Page 76994]]

IV. Other Rates and Charges1 2

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                                   A. Per Each
----------------------------------------------------------------------------------------------------------------
FBI...........................  Immunization....................          $22.00          $31.00          $32.00
----------------------------------------------------------------------------------------------------------------
                            B. Family Member Rate (Formerly Military Dependents Rate)
----------------------------------------------------------------------------------------------------------------
                                                                           11.45
----------------------------------------------------------------------------------------------------------------
                    C. Reimbursement Rates for Drugs Requested by Outside Providers \6\ \15\
 
                  D. Ancillary Services Requested by an Outside Provider--Per Procedure \7\ \5\
----------------------------------------------------------------------------------------------------------------
DB............................  Laboratory procedures requested            15.00           22.00           23.00
                                 by an outside provider CPT '00
                                 Weight Multiplier.
DC, DI........................  Radiology procedures requested             79.00          115.00          120.00
                                 by an outside provider CPT '00
                                 Weight Multiplier.
----------------------------------------------------------------------------------------------------------------
                                       E. Dental Rate--Per Procedure \11\
----------------------------------------------------------------------------------------------------------------
                                Dental Services.................           73.00          112.00          117.00
                                ADA code weight multiplier.
----------------------------------------------------------------------------------------------------------------
                                        F. Ambulance Rate--Per Hour \12\
----------------------------------------------------------------------------------------------------------------
FEA...........................  Ambulance.......................           81.00          113.00          120.00
----------------------------------------------------------------------------------------------------------------
                                 G. AirEvac Rate--Per Trip (24 Hour Period) \13\
----------------------------------------------------------------------------------------------------------------
                                AirEvac Services--Ambulatory....          339.00          473.00          499.00
                                AirEvac Service--Litter.........          989.00        1,379.00        1,454.00
----------------------------------------------------------------------------------------------------------------
                                       H. Observation Rate--Per Hour \14\
----------------------------------------------------------------------------------------------------------------
                                Observation Services--Hour......           20.00           28.00           30.00
----------------------------------------------------------------------------------------------------------------

V. Elective Cosmetic Surgery Procedures and Rates

----------------------------------------------------------------------------------------------------------------
                                                        Current
                                  International        procedural
  Cosmetic surgery procedure      classification   terminology (CPT)    FY 2001 charge \9\     Amount of charge
                                 diseases (ICD-9)         \8\
----------------------------------------------------------------------------------------------------------------
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 Rhytidectomy...........  86.82, 86.22.....  15824............  Inpatient Surgical      (a b)
                                                                       Care Per Diem or APV.
Blepharoplasty................  08.70, 08.44.....  15820, 15821,      Inpatient Surgical      (a b c)
                                                    15822, 15823.      Care Per Diem or APV.
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           86.83............  15876, 15877,      Inpatient Surgical      (a b c)
 region\10\.                                        15878, 15879.      Care Per Diem or APV
                                                                       or applicable
                                                                       Outpatient Clinic
                                                                       Rate.
Rhinoplasty...................  21.87, 21.86.....  30400, 30410.....  Inpatient Surgical      (a b c)
                                                                       Care Per Diem or APV
                                                                       or applicable
                                                                       Outpatient Clinic
                                                                       Rate.
Scar Revisions beyond CHAMPUS.  86.84............  1578.............  Inpatient Surgical      (a b c)
                                                                       Care Per Diem or APV
                                                                       or applicable
                                                                       Outpatient Clinic
                                                                       Rate.
Mandibular or Maxillary         76.41............  21194............  Inpatient Surgical      (a b c)
 Repositioning.                                                        Care Per Diem or APV
                                                                       or applicable
                                                                       Outpatient Clinic
                                                                       Rate.
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............  15836/15832......  Inpatient Surgical      (a b)
                                                                       Care Per Diem or APV.
Refractive surgery............  .................  .................  APY or applicable       (b c e)
                                                                       Outpatient Clinic
                                                                       Rate.
    Radial Keratotomy.........  .................  65771............  ......................

[[Page 76995]]

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

Notes on Cosmetic Surgery Charges

    \a\ Per diem charges for inpatient surgical care services are 
listed in section I.B. (See notes 8 through 10, below, for further 
details on reimbursable rates.)
    \b\ Charges for ambulatory procedure visits (formerly same day 
surgery) are listed in section III. (See notes 8 through 10, 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.
    \d\ Charge is solely determined by the location of where the 
care is provided and is not to be based on any other criteria. An 
APV rate can only be billed if the location has been established as 
an APU following all required DoD guidelines and instructions.
    \e\ Refer to Office of the Assistant Secretary of Defense 
(Health Affairs) Policy on Vision Correction Via Laser Surgery For 
Non-Active Duty Beneficiaries, April 7, 2000, for further guidance 
on billing for these services. It can be downloaded from: http://www.tricare.osd.mil/policy/2000poli.htm.

Notes on Reimbursement 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.
    \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.
    MTFs without inpatient services, whose providers are performing 
inpatient care in a civilian facility for a DoD beneficiary, can 
bill payers the percentage of the charge that represents 
professional services as provided in \1\ above. The ASA rate used in 
these cases, based on the absence of a ASA rate for the facility, 
will be based on the average ASA rate for the type of metropolitan 
statistical area the MTF resides, large urban, other urban/rural, or 
overseas (see paragraph I.C.1.). The Uniform Business Office must 
receive documentation of care provided in order to produce a bill.
    \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

B: Outpatient Care (Functional Category)
BA: Medical Care (Summary Account)
BAA: Internal Medicine (Subaccount)

    \5\ 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 and BE APV rates are to be used only 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 or BE. In addition, APV rates may only be 
utilized for clinics where there is a clinic rate established. For 
example, BLC, Neuromuscular Screening, no longer has an established 
rate. Therefore, an APU cannot be defined and an APV cannot be 
billed for this clinic.
    \6\ Third party payers (such as insurance companies) shall be 
billed for prescription services when beneficiaries who have medical 
insurance obtain medications from MTFs that are prescribed by 
providers external to the MTF (e.g., physicians and dentists). 
Eligible beneficiaries (family members or retirees with medical 
insurance) are not liable personally 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 DoD-wide 
average cost of the drug, calculated by National Drug Code (NDC) 
number. The prescription charge is calculated by multiplying the 
number of units (e.g., tablets or capsules) by the unit cost and 
adding $6.00 for the cost of dispensing the prescription. Dispensing 
costs include overhead, supplies, and labor, etc. to fill the 
prescription.
    The list of drug reimbursement rates is too large to include in 
this document. Those rates are available from the TRICARE Management 
Activity's Uniform Business Office website: http://www.tricare.osd.mil/ebc/rm/rm_home.html.
    \7\ The list of FY 2001 rates for ancillary services requested 
by outside providers and obtained at a MTF is too large to include 
in this document. Those rates are available from the TRICARE 
Management Activity's Uniform Business Office website: http://www.tricare.osd.mil/ebc/rm/rm_home.html.
    Charges for ancillary services requested by an outside provider 
(e.g., physicians and dentists) are relevant to the Third Party 
Collection Program. Third party payers (such as insurance companies) 
shall be billed for ancillary services when beneficiaries who

[[Page 76996]]

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 00) code by either the laboratory or radiology 
multiplier (section IV.D.). Radiology procedures performed by 
Nuclear Medicine use the same methodology as Radiology for 
calculating a charge because their workload and expenses are 
included in the establishment of the Radiology multiplier.
    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.
    \8\ The attending physician is to complete the CPT 00 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.
    \9\ Family members of active duty personnel, retirees and their 
family members, and survivors shall be charged elective cosmetic 
surgery rates. Elective cosmetic surgery procedures information is 
contained in section V. The patient shall be charged the rate as 
specified in the FY 2001 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., 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.)
    \10\ Each regional lipectomy shall carry a separate charge. 
Regions include head and neck, abdomen, flanks, and hips.
    \11\ Dental service rates are based on a dental rate multiplied 
by the DoD established weight for the American Dental Association 
(ADA) code performed. For example, for ADA code 00270, bite wing 
single film, the weight is 0.15. The weight of 0.15 is multiplied by 
the appropriate rate, IMET, IAR, or Full/Third Party rate to obtain 
the charge. If the Full/Third Party rate is used, then the charge 
for this ADA code will be $17.55 ($117 x .15 = $17.55).
    The list of FY 2001 ADA codes and weights for dental services is 
too large to include in this document. Those rates are available 
from the TRICARE Management Activity's Uniform Business Office 
website: http://www.tricare.osd.mil/ebc/rm/rm_home.html.
    \12\ Ambulance charges shall be based on hours of service in 15 
minute increments. The rates listed in section IV.F. 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.).
    \13\ Air in-flight medical care reimbursement charges are 
determined by the status of the patient (ambulatory or litter) and 
are per patient during a 24-hour period. 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.
    \14\ Observation Services are billed at the hourly charge. Begin 
counting when the patient is placed in the observation bed and round 
to the nearest hour. For example, if a patient has received 1 hour 
and 20 minutes of observation, then you bill for 1 hour of service. 
If the status of a patient changes to inpatient, the charges for 
observation services are added to the DRG assigned to the case and 
not separately billed. 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.
    \15\ Final rule 32 CFR Part 220, published February 16, 2000, 
eliminated the dollar threshold for high cost ancillary services and 
the associated term ``high cost ancillary service.'' The phrase 
``high cost ancillary service'' is replaced with the phrase 
``ancillary services requested by an outside provider.'' The 
elimination of the threshold also eliminated 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) exceeds 
$25.00. The elimination of the threshold is effective as per date 
stated in final rule 32 CFR Part 220.

Attachment 1

                       Adjusted Standardized Amounts (ASA) by Military Treatment Facility
----------------------------------------------------------------------------------------------------------------
                                                                  Full cost  Interagency
        DMISID                 MTF name               SERV          rate         rate      IMET rate   TPC rate
----------------------------------------------------------------------------------------------------------------
0003.................  Lyster AH--Ft. Rucker...  A.............      $6,637       $6,286      $3,286      $6,637
0004.................  502nd Med Grp--Maxwell    F.............       6,984        6,614       3,458       6,984
                        AFB.
0005.................  Bassett ACH--Ft.          A.............       7,152        6,774       3,541       7,152
                        Wainwright.
0006.................  3rd Med Grp--Elmendorf    F.............       7,041        6,668       3,486       7,041
                        AFB.
0009.................  56th Med Grp--Luke AFB..  F.............       5,986        5,697       2,978       5,986
0014.................  60th Med Grp--Travis AFB  F.............       9,912        9,387       4,907       9,912
0018.................  30th Med Grp--Vandenberg  F.............       7,035        6,663       3,483       7,035
                        AFB.
0019.................  95th Med Grp--Edwards     F.............       7,004        6,633       3,468       7,004
                        AFB.
0024.................  NH Camp Pendleton.......  N.............       7,614        7,245       3,787       7,614
0028.................  NH Lemoore..............  N.............       6,997        6,627       3,465       6,997
0029.................  NH San Diego............  N.............       9,744        9,273       4,847       9,744
0030.................  NH Twenty Nine Palms....  N.............       6,111        5,815       3,039       6,111
0032.................  Evans ACH--Ft. Carson...  A.............       6,946        6,578       3,439       6,946
0033.................  10th Med Grp--USAF        F.............       6,994        6,623       3,463       6,994
                        Academy.
0037.................  Walter Reed AMC--         A.............       9,010        8,574       4,482       9,010
                        Washington DC.
0038.................  NH Pensacola............  N.............       8,939        8,465       4,426       8,939
0039.................  NH Jacksonville.........  N.............       7,537        7,173       3,749       7,537
0042.................  96th Med Grp--Eglin AFB.  F.............       8,309        7,869       4,114       8,309
0043.................  325th Med Grp--Tyndall    F.............       7,002        6,631       3,467       7,002
                        AFB.
0045.................  6th Med Grp--MacDill AFB  F.............       5,991        5,702       2,980       5,991
0047.................  Eisenhower AMC--Ft.       A.............       8,550        8,098       4,233       8,550
                        Gordon.
0048.................  Martin ACH--Ft. Benning.  A.............       7,987        7,564       3,954       7,987
0049.................  Winn ACH--Ft. Stewart...  A.............       6,644        6,292       3,289       6,644
0052.................  Tripler AMC--Ft. Shafter  A.............       9,533        9,029       4,720       9,533
0053.................  366th Med Grp--Mountain   F.............       6,982        6,612       3,457       6,982
                        Home AFB.
0055.................  375th Med Grp--Scott AFB  F.............       7,625        7,256       3,793       7,625
0056.................  NH Great Lakes..........  N.............       6,063        5,770       3,016       6,063

[[Page 76997]]

 
0057.................  Irwin AH--Ft. Riley.....  A.............       6,521        6,176       3,229       6,521
0060.................  Blanchfield ACH--Ft.      A.............       6,605        6,255       3,270       6,605
                        Campbell.
0061.................  Ireland ACH--Ft. Knox...  A.............       6,829        6,467       3,381       6,829
0064.................  Bayne-Jones ACH--Ft.      A.............       6,573        6,225       3,254       6,573
                        Polk.
0066.................  89th Med Grp--Andrews     F.............       8,062        7,672       4,010       8,062
                        AFB.
0067.................  NNMC Bethesda...........  N.............       9,786        9,313       4,868       9,786
0073.................  81st Med Grp--Keesler     F.............       8,772        8,308       4,343       8,772
                        AFB.
0075.................  Wood ACH--Ft. Leonard     A.............       6,539        6,193       3,237       6,539
                        Wood.
0078.................  55th Med Grp--Offutt AFB  F.............       8,697        8,236       4,306       8,697
0079.................  99th Med Grp--Nellis AFB  F.............       6,002        5,712       2,986       6,002
0083.................  377th Med Grp--Kirtland   F.............       6,971        6,602       3,452       6,971
                        AFB.
0084.................  49th Med Grp--Holloman    F.............       7,004        6,633       3,468       7,004
                        AFB.
0086.................  Keller ACH--West Point..  A.............       7,296        6,909       3,612       7,296
0089.................  Womack AMC--Ft. Bragg...  A.............       7,817        7,403       3,870       7,817
0091.................  NH Camp LeJeune.........  N.............       6,744        6,387       3,339       6,744
0092.................  NH Cherry Point.........  N.............       6,788        6,429       3,361       6,788
0093.................  319th Med Grp--Grand      F.............       7.032        6,660       3,482       7.032
                        Forks AFB.
0094.................  5th Med Grp--Minot AFC..  F.............       6,857        6,494       3,395       6,857
0095.................  74th Med Grp--Wright-     F.............      10,371        9,822       5,135      10,371
                        Patterson AFB.
0096.................  72nd Med Grp--Tinker AFB  F.............       6,001        5,711       2,985       6,001
0097.................  97th Med Grp--Altus AFB.  F.............       6,976        6,607       3,454       6,976
0098.................  Reynolds ACH--Ft. Sill..  A.............       6,831        6,469       3,382       6,831
0100.................  NH Newport..............  N.............       6,002        5,712       2,986       6,002
0101.................  20th Med Grp--Shaw AFB..  F.............       6,964        6,595       3,448       6,964
0103.................  NH Charleston...........  N.............       6,879        6,514       3,406       6,879
0104.................  NH Beaufort.............  N.............       6,871        6,507       3,402       6,871
0105.................  Moncrief ACH--Ft.         A.............       6,961        6,592       3,446       6,961
                        Jackson.
0106.................  28th Med Grp--Ellsworth   F.............       6,939        6,572       3,436       6,939
                        AFB.
0108.................  Wm Beaumont AMC--Ft.      A.............       8,329        7,888       4,124       8,329
                        Bliss.
0109.................  Brooke AMC--Ft. Sam       A.............       8,511        8,099       4,233       8,511
                        Houston.
0110.................  Darnall AH--Ft. Hood....  A.............       8,606        8,151       4,261       8,606
0112.................  7th Med Grp--Dyess AFB..  F.............       6,892        6,528       3,413       6,892
0113.................  82nd Med Grp--Sheppard    F.............       6,903        6,537       3,418       6,903
                        AFB.
0117.................  59th Med Wing--Lackland   F.............       8,640        8,222       4,297       8,640
                        AFB.
0119.................  75th Med Grp--Hill AFB..  F.............       5,983        5,693       2,976       5,983
0120.................  1st Med Grp--Langley AFB  F.............       5,954        5,666       2,962       5,954
0121.................  McDonald ACH--Ft. Eustis  A.............       5,649        5,376       2,810       5,649
0123.................  Dewitt AH--Ft. Belvoir..  A.............       8,237        7,839       4,097       8,237
0124.................  NH Portsmouth...........  N.............       7,469        7,107       3,715       7,469
0125.................  Madigan AMC--Ft. Lewis..  A.............      11,018       10,435       5,455      11,018
0126.................  NH Bremerton............  N.............       8,165        7,733       4,043       8,165
0127.................  NH Oak Harbor...........  N.............       6,283        5,979       3,125       6,283
0129.................  90th Med Grp--F.E.        F.............       6,989        6,619       3,460       6,989
                        Warren AFB.
0131.................  Weed ACH--Ft. Irwin.....  A.............       7,003        6,633       3,467       7,003
0449.................  24th Med Grp--Howard....  F.............       9,489        9,045       3,872       9,489
0606.................  95th CSH--Heidelberg....  A.............       9,489        9,045       3,872       9,489
0607.................  Landstuhl Rgn MC........  A.............       9,489        9,045       3,872       9,489
0609.................  67th CSH--Wurzburg......  A.............       9,489        9,045       3,872       9,489
0612.................  121st Gen Hosp--Seoul...  A.............       9,489        9,045       3,872       9,489
0615.................  NH Guantanamo Bay.......  N.............       9,489        9,045       3,872       9,489
0616.................  NH Roosevelt Roads......  N.............       9,489        9,045       3,872       9,489
0617.................  NH Naples...............  N.............       9,489        9,045       3,872       9,489
0618.................  NH Rota.................  N.............       9,489        9,045       3,872       9,489
0620.................  NH Guam.................  N.............       9,489        9,045       3,872       9,489
0621.................  NH Okinawa..............  N.............       9,489        9,045       3,872       9,489
0622.................  NH Yokosuka.............  N.............       9,489        9,045       3,872       9,489
0623.................  NH Keflavik.............  N.............       9,489        9,045       3,872       9,489
0624.................  BH Sigonella............  N.............       9,489        9,045       3,872       9,489
0633.................  48th Med Grp--RAF         F.............       9,489        9,045       3,872       9,489
                        Lakenheath.
0635.................  39th Med Grp--Incirlik    F.............       9,489        9,045       3,872       9,489
                        AB.
0638.................  51st Med Grp--Osan AB...  F.............       9,489        9,045       3,872       9,489
0639.................  35th Med Grp--Misawa....  F.............       9,489        9,045       3,872       9,489
0640.................  374th Med Grp--Yokota AB  F.............       9,489        9,045       3,872       9,489
0805.................  52nd Med Grp--            F.............       9,489        9,045       3,872       9,489
                        Spangdahlem.
0808.................  31st Med Grp--Aviano....  F.............       9,489        9,045       3,872       9,489
----------------------------------------------------------------------------------------------------------------


[[Page 76998]]

[FR Doc. 00-31242 Filed 12-7-00; 8:45 am]
BILLING CODE 5001-10-M