[Federal Register Volume 66, Number 247 (Wednesday, December 26, 2001)]
[Notices]
[Pages 66477-66485]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-31663]


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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 Public Law 87-693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to 
the Director of the Office of Management and Budget by Executive Order 
No. 11541 of July 1, 1970 (35 FR 10737), the two sets of rates outlined 
below are hereby established. These rates are for use in connection 
with the recovery, from tortiously liable third persons, of the cost of 
hospital and medical care and treatment furnished by the United States 
(Part 43, Chapter I, Title 28, Code of Federal Regulations) through 
three separate Federal agencies. The rates have been established in 
accordance with the requirements of OMB Circular A-25, requiring 
reimbursement of the full cost of all services provided and will remain 
in effect until further notice. The rates for VA that were published in 
the Federal Register on October 31, 2000 remain in effect until further 
notice. The rates are as follows:

1. Department of Defense

    The 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 size, the sections 
containing the Drug Reimbursement Rates (section III.D.) and the rates 
for Ancillary Services Requested by Outside Providers (section III.E.) 
are not included in this package. Those rates are available from the 
TRICARE Management Activity's Uniform Business Office web site:
http://www.tricare.osd.mil/ebc/rm_home/imcp/ubo/ubo_01.htm. The medical 
and dental service rates in this package (including the rates for 
ancillary services and other procedures requested by outside providers) 
are effective October 1, 2001. Pharmacy rates are updated on an as 
needed basis.

2. Health and Human Services

    The tortiously liable rates for Indian Health Service health 
facilities are based on Medicare cost reports. 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 the Contract Health fund, that were used to support the 
inpatient and outpatient workload. 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.
    Separate rates per inpatient day and outpatient visit were computed 
for Alaska and the rest of the United States.

[[Page 66478]]

This gives proper weight to the higher cost of operating medical 
facilities in Alaska.

1. Department of Defense

    For the Department of Defense, effective October 1, 2001 and 
thereafter:

Inpatient, Outpatient and Other Rates and Charges

I. Inpatient Rates 1 2

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
                        Per inpatient day                           education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
A. Burn Center..................................................       $3,550.00       $6,156.00       $6,492.00
B. All Other Inpatient Services (Based on Diagnosis Related
 Groups (DRG) \3\...............................................
----------------------------------------------------------------------------------------------------------------

1. Average FY 2002 Direct Care Inpatient Reimbursement Rates

----------------------------------------------------------------------------------------------------------------
                                                                                                   Other (full/
                    Adjusted standard amount                           IMET         Interagency    third party)
----------------------------------------------------------------------------------------------------------------
Large Urban.....................................................       $3,625.00       $6,170.00       $6,486.00
Other Urban/Rural...............................................        3,771.00        6,694.00        7,069.00
Overseas........................................................        3,958.00        9,293.00        9,742.00
----------------------------------------------------------------------------------------------------------------

2. Overview
    The 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.B.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. 
An outlier refers to a patient's LOS, which is either atypically short 
or long. They are determined by short or long stay outlier thresholds. 
Inliers, i.e., those patients who fall within the bounds of the outlier 
thresholds, receive DRG weights that represent their relative resource 
intensity.
    Each Military Treatment Facility (MTF) providing inpatient care has 
a separate 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. An example of how to apply a specific military 
treatment facility's ASA rate to a DRG standardized weight to arrive at 
the costs to be recovered is contained in paragraph I.B.3. below.

3. Example of Adjusted Standardized Amounts for Inpatient Stays

    Figure 1 shows examples for a non-teaching 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 (i.e. the DoD measure of workload credit derived from biometrics 
dispositions weighted by CHAMPUS DRG weights) for an inlier case is the 
CHAMPUS weight of 2.0860. (DRG statistics shown are from FY 2000.)
    c. The MTF-applied ASA rate is $6,849.00 (Reynolds Army Community 
Hospital's third party rate as shown in Attachment 1).
    d. The MTF cost to be recovered is the RWP factor (2.0860) in 
subparagraph 3.b., above, multiplied by the amount ($6,849.00) in 
subparagraph 3.c., above which equals $14,287.00
    e. Cost to be recovered is $14,287.00.

                                     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            2.0860           7.7           5.5             1            29
                        Infection Except
                        Viral Meningitis.
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                                            Area wage        IME                     MTF-Applied
             Hospital                     Location         rate index    adjustment     Group ASA        ASA
----------------------------------------------------------------------------------------------------------------
Reynolds Army Community Hospital..  Other Urban/Rural...        .8996           1.0     $7,069.00     $6,849.00
 
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                                                    Relative weighted product            TPC
           Patient              Length of stay    Days above ---------------------------------------------------
                                                  threshold     Inlier *    Outlier **     Total      Amount ***
----------------------------------------------------------------------------------------------------------------
#1...........................  7 days..........            0       2.0860          000       2.0860   $14,287.00
#2...........................  21 days.........            0       2.0860          000       2.0860    14,287.00

[[Page 66479]]

 
#3...........................  35 days.........            6       2.0860        .7510       2.8370    19,431.00
----------------------------------------------------------------------------------------------------------------
 * DRG Weight
 ** Outlier calculation = 33 percent of per diem weight X number of outlier days. The outlier must meet the
  criteria determined by the outlier threshold, i.e., the number of days beyond which hospitalization LOS is
  considered outside the typical range. These are specific for each DRG.
    =.33 (DRG Weight/Geometric Mean LOS)  x  (Patient LOS-Long Stay Threshold)
    =.33 (2.0860/5.5)  x  (35 - 29)
    =.33 (.37927)  x  6 (take out to five decimal places)
    =.12516 X 6 (carry to five decimal places)
    =.7510 (carry to four decimal places)
 *** MTF-Applied ASA  x  Total RWP

II. Outpatient Rates
A. Per Clinic Visit \1\ \2\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other federal
        MEPRS Code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                                 1. Medical Care
----------------------------------------------------------------------------------------------------------------
BAA...........................  Internal Medicine...............          $50.00         $199.00         $210.00
BAB...........................  Allergy.........................           61.00          113.00          119.00
BAC...........................  Cardiology......................          107.00          199.00          209.00
BAE...........................  Diabetic........................           74.00          137.00          144.00
BAF...........................  Endocrinology (Metabolism)......          124.00          231.00          243.00
BAG...........................  Gastroenterology................          146.00          272.00          286.00
BAH...........................  Hematology......................          225.00          419.00          442.00
BAI...........................  Hypertension....................          198.00          369.00          388.00
BAJ...........................  Nephrology......................          180.00          334.00          352.00
BAK...........................  Neurology.......................          136.00          254.00          267.00
BAL...........................  Outpatient Nutrition............           51.00           95.00          100.00
BAM...........................  Oncology........................          158.00          294.00          310.00
BAN...........................  Pulmonary Disease...............          144.00          267.00          281.00
BAO...........................  Rheumatology....................          116.00          216.00          228.00
BAP...........................  Dermatology.....................           93.00          172.00          182.00
BAQ...........................  Infectious Disease..............          151.00          282.00          297.00
BAR...........................  Physical Medicine...............           94.00          175.00          184.00
BAS...........................  Radiation Therapy...............          142.00          264.00          278.00
BAT...........................  Bone Marrow Transplant..........          154.00          287.00          302.00
BAU...........................  Genetic.........................          343.00          639.00          673.00
BAV...........................  Hyperbaric......................          276.00          513.00          540.00
----------------------------------------------------------------------------------------------------------------
                                                2. Surgical Care
----------------------------------------------------------------------------------------------------------------
BBA...........................  General Surgery.................          162.00          302.00          318.00
BBB...........................  Cardiovascular and Thoracic               291.00          541.00          570.00
                                 Surgery.
BBC...........................  Neurosurgery....................          169.00          314.00          331.00
BBD...........................  Ophthalmology...................          106.00          198.00          209.00
BBE...........................  Organ Transplant................          717.00        1,335.00        1,406.00
BBF...........................  Otolaryngology..................          117.00          217.00          229.00
BBG...........................  Plastic Surgery.................          134.00          249.00          262.00
BBH...........................  Proctology......................           95.00          177.00          186.00
BBI...........................  Urology.........................          131.00          244.00          257.00
BBJ...........................  Pediatric Surgery...............           72.00          133.00          140.00
BBK...........................  Peripheral Vascular Surgery.....           83.00          155.00          163.00
BBL...........................  Pain Management.................          113.00          210.00          222.00
BBM...........................  Vascular and Interventional               351.00          653.00          688.00
                                 Radiology.
----------------------------------------------------------------------------------------------------------------
                                 3. Obstetrical and Gynecological (OB-GYN) Care
----------------------------------------------------------------------------------------------------------------
BCA...........................  Family Planning.................           75.00          139.00          146.00
BCB...........................  Gynecology......................           98.00          182.00          191.00
BCC...........................  Obstetrics......................           78.00          145.00          153.00
BCD...........................  Breast Cancer Clinic............          147.00          274.00          289.00
----------------------------------------------------------------------------------------------------------------
                                                4. Pediatric Care
----------------------------------------------------------------------------------------------------------------
BDA...........................  Pediatric.......................           71.00          133.00          140.00
BDB...........................  Adolescent......................           75.00          139.00          146.00
BDC...........................  Well Baby.......................           49.00           91.00           96.00
----------------------------------------------------------------------------------------------------------------

[[Page 66480]]

 
                                               5. Orthopaedic Care
----------------------------------------------------------------------------------------------------------------
BEA...........................  Orthopaedic.....................          112.00          208.00          219.00
BEB...........................  Cast............................           63.00          117.00          123.00
BEC...........................  Hand Surgery....................           60.00          112.00          118.00
BEE...........................  Orthotic Laboratory.............           72.00          134.00          141.00
BEF...........................  Podiatry........................           63.00          117.00          124.00
BEZ...........................  Chiropractic....................           30.00           56.00           58.00
----------------------------------------------------------------------------------------------------------------
                                    6. Psychiatric and/or Mental Health Care
----------------------------------------------------------------------------------------------------------------
BFA...........................  Psychiatry......................          121.00          226.00          238.00
BFB...........................  Psychology......................           75.00          140.00          148.00
BFC...........................  Child Guidance..................           71.00          132.00          139.00
BFD...........................  Mental Health...................          118.00          219.00          231.00
BFE...........................  Social Work.....................          113.00          211.00          222.00
BFF...........................  Substance Abuse.................          110.00          206.00          216.00
----------------------------------------------------------------------------------------------------------------
                                     7. Family Practice/Primary Medical Care
----------------------------------------------------------------------------------------------------------------
BGA...........................  Family Practice.................           84.00          156.00          165.00
BHA...........................  Primary Care....................           82.00          152.00          160.00
BHB...........................  Medical Examination.............           82.00          152.00          160.00
BHC...........................  Optometry.......................           57.00          106.00          112.00
BHD...........................  Audiology.......................           48.00           90.00           94.00
BHE...........................  Speech Pathology................           91.00          169.00          178.00
BHF...........................  Community Health................           67.00          125.00          131.00
BHG...........................  Occupational Health.............           90.00          167.00          176.00
BHH...........................  TRICARE Outpatient..............           58.00          108.00          114.00
BHI...........................  Immediate Care..................          113.00          211.00          222.00
----------------------------------------------------------------------------------------------------------------
                                            8. Emergency Medical Care
----------------------------------------------------------------------------------------------------------------
BIA...........................  Emergency Medical...............          142.00          264.00          278.00
----------------------------------------------------------------------------------------------------------------
                                             9. Flight Medical Care
----------------------------------------------------------------------------------------------------------------
BJA...........................  Flight Medicine.................           98.00          183.00          192.00
----------------------------------------------------------------------------------------------------------------
                                           10. Underseas Medical Care
----------------------------------------------------------------------------------------------------------------
BKA...........................  Underseas Medicine..............           57.00          107.00          113.00
----------------------------------------------------------------------------------------------------------------
                                          11. Rehabilitative Services
----------------------------------------------------------------------------------------------------------------
BLA...........................  Physical Therapy................           43.00           81.00           85.00
BLB...........................  Occupational Therapy............           87.00          162.00           70.00
----------------------------------------------------------------------------------------------------------------

B. 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
----------------------------------------------------------------------------------------------------------------
BB............................  Surgical Care...................        1,068.00        1,987.00        2,093.00
BE............................  Orthopaedic Care................        1,315.00        2,448.00        2,577.00
All Other                       B clinics other than BB and BE,           297.00          553.00          582.00
                                 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 IIA.
                                 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 66481]]

III. Other Rates and Charges 1 2
A. Per Each

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
FBI...........................  Immunization....................          $18.00          $34.00          $36.00
                                B. Family Member Rate (formerly            11.90
                                 Military Dependents Rate).
                                C. Subsistence Rate.\15\
                                  Standard Rate.................            8.10
                                  Discount Rate.................            6.75
----------------------------------------------------------------------------------------------------------------

D. Reimbursement Rates For Drugs Requested By Outside Providers \6\
E. Ancillary Services Requested by an Outside Provider--Per Procedure 
\7\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
DB............................  Laboratory procedures requested           $19.00          $28.00          $29.00
                                 by an outside provider current
                                 procedural terminology (CPT)
                                 2001 weight multiplier.
DC, DI........................  Radiology procedures requested             38.00           54.00           57.00
                                 by an outside provider CPT 2001
                                 weight multiplier.
----------------------------------------------------------------------------------------------------------------

F. Dental Rate--Per Procedure \11\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                Dental services ADA code weight           $31.00          $73.00          $77.00
                                 multiplier.
----------------------------------------------------------------------------------------------------------------

G. Ambulance Rate--Per Hour \12\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
FEA...........................  Ambulance.......................          $67.00         $124.00         $131.00
----------------------------------------------------------------------------------------------------------------

H. AirEvac Rate--Per Trip (24 hour period) \13\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                AirEvac Services--Ambulatory....         $257.00         $479.00         $505.00
                                AirEvac Services--Litter........          751.00        1,397.00        1,471.00
----------------------------------------------------------------------------------------------------------------

I. Observation Rate--Per hour \14\

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
        MEPRS code \4\                  Clinical service            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
                                Observation Services--Hour......          $13.00          $24.00          $26.00
----------------------------------------------------------------------------------------------------------------


[[Page 66482]]

IV. Elective Cosmetic Surgery Procedures and Rates

----------------------------------------------------------------------------------------------------------------
                                    International    Current procedural
   Cosmetic surgery procedure      classification     terminology (CPT)    FY 2002 charge \9\       Amount of
                                  diseases (ICD-9)           \8\                                      Charge
----------------------------------------------------------------------------------------------------------------
Mammaplasty--augmentation......  85.50, 85.32,       19325, 19324,       Inpatient Charge per    (\a\)
                                  85.31.              19318.              DRG or APV.            (\b\)
Mastopexy......................  85.60.............  19316.............  Inpatient Charge per    (a b c)
                                                                          DRG Or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Facial Rhytidectomy............  86.82, 86.22......  15824.............  Inpatient Charge per    (a b)
                                                                          DRG or APV.
Blepharoplasty.................  08.70, 08.44......  15820, 15821,       Inpatient Charge per    (a b c)
                                                      15822, 15823.       DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Mentoplasty (Augmentation/       76.68, 76.67......  21208, 21209......  Inpatient Charge per    (a b c)
 Reduction).                                                              DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Abdominoplasty.................  86.83.............  15831.............  Inpatient Charge per    (a b c)
                                                                          DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Lipectomy Suction per region     86.83.............  15876, 15877,       Inpatient Charge per
 \10\.                                                15878, 15879.       DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Rhinoplasty....................  21.87, 21.86......  30400, 30410......  Inpatient Charge per    (a b c)
                                                                          DRG Or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Scar Revisions beyond CHAMPUS..  86.84.............  1578..............  Inpatient Charge per    (a b c)
                                                                          DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Mandibular or Maxillary          76.41.............  21194.............  Inpatient Charge per    (a b c)
 Repositioning.                                                           DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Dermabrasion...................  86.25.............  15780.............  Inpatient Charge per    (a b c)
                                                                          DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Hair Restoration...............  86.64.............  15775.............  Inpatient Charge per    (a b c)
                                                                          DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Removing Tattoos...............  86.25.............  15780.............  Inpatient Charge per    (a b c)
                                                                          DRG or APV or
                                                                          applicable Outpatient
                                                                          Clinic Rate.
Chemical peel..................  86.24.............  15790.............  Inpatient charge per    (a b c)
                                                                          DRG or APV or
                                                                          applicable Outpatient
                                                                          clinic rate.
Arm/thigh dermolipectomy.......  86.83.............  15836/15832.......  Inpatient charge per    (a b)
                                                                          DRG or APV.
Refractive surgery.............  ..................  ..................  APV or applicable       (b c e)
                                                                          outpatient clinic
                                                                          rate.
Radial keratotomy..............  ..................  65771.............  ......................  ...............
Other procedure (if applies to   ..................  66999.............  ......................
 laser or other refractive
 surgery).
Otoplasty......................    ................  69300.............  APV or applicable       (b c)
                                                                          outpatient clinic
                                                                          rate.
Brow lift......................  86.3..............  15839.............  Inpatient charge per    (a b c)
                                                                          DRG or APV or
                                                                          applicable outpatient
                                                                          clinic rate.
----------------------------------------------------------------------------------------------------------------

Notes on Cosmetic Surgery Charges

    \a\ Charges for Inpatient surgical care services are based on 
the cost per DRG. (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 II.B. (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. 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 Reimbursable Rates

    \1\ Percentages can be applied when preparing bills for both 
inpatient and outpatient services. Pursuant to the provisions of 10 
U.S.C. 1095, the inpatient Diagnosis Related Groups and inpatient 
per diem percentages are 96 percent hospital and 4 percent 
professional charges. The outpatient per visit percentages are 89 
percent outpatient services and 11 percent professional charges.
    \2\ DoD civilian employees located in overseas areas shall be 
rendered a bill when services are performed.
    \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 Centers for Medicare and Medicaid Services (CMS) 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.B.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:

[[Page 66483]]

Outpatient Care (Functional Category), B (MEPRS CODE), Medical Care 
(Summary Account), BA (MEPRS CODE), Internal Medicine (Subaccount), 
BAA (MEPRS CODE).
    \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 lowest cost for the generic 
drugs with the same dosage and strength. 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 web site, 
http://www.tricare.osd.mil/ebc/rm_home/imcp/ubo/ubo_01.htm.
    \7\ The list of rates for ancillary services requested by 
outside providers and obtained at a Military Treatment Facility 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_home/imcp/ubo/ubo_01.htm.
    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 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) 2001 code by 
either the laboratory or radiology multiplier (section III.E.). 
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 2001 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 procedure information is 
contained in section IV. The patient shall be charged the rate as 
specified in the FY 2002 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 
care services based on the cost per DRG, ambulatory procedure visits 
as contained in section II.B. or the appropriate outpatient clinic 
rate in sections II.A. 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 $11.55 ($77  x  .15 = $11.55).
    The list of 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 web site, 
http://www.tricare.osd.mil/ebc/rm_home/imcp/ubo/ubo_01.htm.
    \12\ Ambulance charges shall be based on hours of service in 15 
minute increments. The rates listed in section III.G. 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\ Subsistence is billed under the Medical Services Account 
(MSA) Program only. The MSA office shall collect subsistence charges 
from all persons, including inpatients and transient patients not 
entitled to food service at Government expense. Please refer to DoD 
6010.15-M, Military Treatment Facility Uniform Business Office (UBO) 
Manual, April 1997 and the DoD 7000.14-R, ``Department of Defense 
Financial Management Regulation'', Volume 12, Chapter 19 for 
guidance on the the use of these rates.

             Attachment 1.--FY02 Adjusted Standardized Amounts (ASA) by Military Treatment Facility
----------------------------------------------------------------------------------------------------------------
                                                                    Interagency
     DMISID          MTF name          Serv       Full cost rate       rate          IMET rate       TPC rate
----------------------------------------------------------------------------------------------------------------
0003...........  Lyster AH--Ft.   A                       $6,703          $6,348          $3,576          $6,703
                  Rucker.
0005...........  Bassett ACH--    A                        7,241           6,856           3,863           7,241
                  Ft. Wainwright.
0006...........  3rd Med Grp--    F                        7,109           6,732           3,793           7,109
                  Elmendorf AFB.

[[Page 66484]]

 
0009...........  56th Med Grp--   F                        6,474           6,159           3,618           6,474
                  Luke AFB.
0014...........  60th Med Grp--   F                        9,946           9,419           5,306           9,946
                  Travis AFB.
0024...........  NH Camp          N                        8,687           8,264           4,855           8,687
                  Pendleton.
0028...........  NH Lemoore.....  N                        7,034           6,661           3,752           7,034
0029...........  NH San Diego...  N                       10,904          10,374           6,094          10,904
0030...........  NH Twenty Nine   N                        6,596           6,274           3,686           6,596
                  Palms.
0032...........  Evans ACH--Ft.   A                        6,985           6,615           3,726           6,985
                  Carson.
0033...........  10th Med Grp--   F                        7,062           6,687           3,767           7,062
                  USAF Academy.
0037...........  Walter Reed      A                       10,384           9,878           5,803          10,384
                  AMC--Washingto
                  n DC.
0038...........  NH Pensacola...  N                        8,704           8,242           4,643           8,704
0039...........  NH Jacksonville  N                        8,539           8,123           4,772           8,539
0042...........  96th Med Grp--   F                        8,747           8,283           4,666           8,747
                  Eglin AFB.
0045...........  6th Med Grp--    F                        6,482           6,167           3,623           6,482
                  MacDill AFB.
0047...........  Eisenhower AMC-- A                        8,677           8,217           4,629           8,677
                  Ft. Gordon.
0048...........  Martin ACH--Ft.  A                        8,118           7,688           4,331           8,118
                  Benning.
0049...........  Winn ACH--Ft.    A                        6,989           6,618           3,728           6,989
                  Stewart.
0052...........  Tripler AMC--    A                       10,134           9,597           5,406          10,134
                  Ft. Shafter.
0053...........  366th Med Grp--  F                        7,056           6,682           3,764           7,056
                  Mountain Home
                  AFB.
0055...........  375th Med Grp--  F                        8,579           8,161           4,794           8,579
                  Scott AFB.
0056...........  NH Great Lakes.  N                        6,538           6,220           3,654           6,538
0057...........  Irwin AH--Ft.    A                        6,498           6,154           3,467           6,498
                  Riley.
0060...........  Blanchfield      A                        6,577           6,228           3,509           6,577
                  ACH--Ft
                  Campbell.
0061...........  Ireland ACH--    A                        6,467           6,124           3,450           6,467
                  Ft. Knox.
0064...........  Bayne-Jones      A                        6,602           6,252           3,522           6,602
                  ACH--Ft. Polk.
0066...........  89th Med Grp--   F                        8,807           8,378           4,922           8,807
                  Andrews AFB.
0067...........  NNMC Bethesda..  N                       10,913          10,382           6,099          10,913
0073...........  81st Med Grp--   F                       10,213           9,671           5,448          10,213
                  Keesler AFB.
0075...........  Wood ACH--Ft.    A                        6,572           6,223           3,506           6,572
                  Leonard Wood.
0078...........  55th Med Grp--   F                        9,245           8,755           4,932           9,245
                  Offutt AFB.
0079...........  99th Med Grp--   F                        6,495           6,179           3,630           6,495
                  Nellis AFB.
0084...........  49th Med Grp--   F                        7,068           6,693           3,771           7,068
                  Holloman AFB.
0086...........  Keller ACH--     A                        7,342           6,953           3,917           7,342
                  West Point.
0089...........  Womack AMC--Ft.  A                        7,586           7,184           4,047           7,586
                  Bragg.
0091...........  NH Camp LeJeune  N                        6,694           6,339           3,571           6,694
0092...........  NH Cherry Point  N                        6,809           6,448           3,632           6,809
0093...........  319th Med Grp--  F                        6,966           6,597           3,716           6,966
                  Grand Forks
                  AFB.
0094...........  5th Med Grp--    F                        6,965           6,595           3,715           6,965
                  Minot AFB.
0095...........  74th Med Grp--   F                       11,385          10,781           6,073          11,385
                  Wright-
                  Patterson AFB.
0098...........  Reynolds ACH--   A                        6,849           6,486           3,654           6,849
                  Ft. Sill.
0100...........  NH Newport.....  N                        6,486           6,170           3,625           6,486
0101...........  20th Med Grp--   F                        7,028           6,656           3,749           7,028
                  Shaw AFB.
0104...........  NH Beaufort....  N                        6,940           6,572           3,702           6,940
0105...........  Moncrief ACH--   A                        7,011           6,639           3,740           7,011
                  Ft. Jackson.
0106...........  28th Med Grp--   F                        7,049           6,675           3,760           7,049
                  Ellsworth AFB.
0108...........  Wm Beaumont      A                        8,575           8,120           4,575           8,575
                  AMC--Ft. Bliss.
0109...........  Brooke AMC--Ft.  A                        9,404           8,946           5,255           9,404
                  Sam Houston.
0110...........  Darnall AH--Ft.  A                        7,904           7,485           4,216           7,904
                  Hood.
0112...........  7th Med Grp--    F                        6,999           6,628           3,734           6,999
                  Dyess AFB.
0113...........  82nd Med Grp--   F                        6,970           6,600           3,718           6,970
                  Sheppard AFB.
0117...........  59th Med Wing    F                        9,977           9,491           5,575           9,977
                  F--Lackland
                  AFB.
0120...........  1st Med Grp--    F                        6,421           6,108           3,588           6,421
                  Langley AFB.
0121...........  McDonald ACH--   A                        6,103           5,806           3,411           6,103
                  Ft. Eustis.
0123...........  Dewitt AH--Ft.   A                        8,131           7,735           4,544           8,131
                  Belvoir.
0124...........  NH Portsmouth..  N                        8,355           7,949           4,669           8,355
0125...........  Madigan AMC--    A                       11,847          11,218           6,320          11,847
                  Ft. Lewis.
0126...........  NH Bremerton...  N                        8,400           7,955           4,481           8,400
0127...........  NH Oak Harbor..  N                        6,709           6,382           3,749           6,709
0131...........  Weed ACH--Ft.    A                        7,064           6,689           3,769           7,064
                  Irwin.
0606...........  95th CSH--       A                        9,742           9,293           3,958           9,742
                  Heidelberg.
0607...........  Landstuhl Rgn    A                        9,742           9,293           3,958           9,742
                  MC.
0609...........  67th CSH--       A                        9,742           9,293           3,958           9,742
                  Wurzburg.
0612...........  121st Gen Hosp-- A                        9,742           9,293           3,958           9,742
                  Seoul.
0615...........  NH Guantanamo    N                        9,742           9,293           3,958           9,742
                  Bay.
0616...........  NH Roosevelt     N                        9,742           9,293           3,958           9,742
                  Roads.
0617...........  NH Naples......  N                        9,742           9,293           3,958           9,742
0618...........  NH Rota........  N                        9,742           9,293           3,958           9,742
0620...........  NH Guam........  N                        9,742           9,293           3,958           9,742
0621...........  NH Okinawa.....  N                        9,742           9,293           3,958           9,742
0622...........  NH Yokosuka....  N                        9,742           9,293           3,958           9,742
0623...........  NH Keflavik....  N                        9,742           9,293           3,958           9,742
0624...........  BH Sigonella...  N                        9,742           9,293           3,958           9,742

[[Page 66485]]

 
0633...........  48th Med Grp--   F                        9,742           9,293           3,958           9,742
                  RAF Lakenheath.
0635...........  39th Med Grp--   F                        9,742           9,293           3,958           9,742
                  Incirlik AB.
0638...........  51st Med Grp--   F                        9,742           9,293           3,958           9,742
                  Osan AB.
0639...........  35th Med Grp--   F                        9,742           9,293           3,958           9,742
                  Misawa.
0640...........  374th Med Grp--  F                        9,742           9,293           3,958           9,742
                  Yokota AB.
0805...........  52nd Med Grp--   F                        9,742           9,293           3,958           9,742
                  Spangdahlem.
0808...........  31st Med Grp--   F                        9,742           9,293           3,958           9,742
                  Aviano.
----------------------------------------------------------------------------------------------------------------

2. Department of Health and Human Services

    For the Department of Health and Human Services, Indian Health 
Service, effective October 1, 2001 and thereafter:

               Hospital Care Inpatient Day
    General Medical Care.................................
    Alaska...............................................       $2,025
    Rest of the United States............................        1,571
               Outpatient Medical Treatment
    Outpatient Visit.....................................
    Alaska...............................................          363
    Rest of the United States............................          196
 

    Beginning October 1, 2001, the rates prescribed herein superceded 
those established by the Director of the Office of Management and 
Budget October 31, 2000 (FR Doc. 00-27726).

Mitchell Daniels, Jr.,
Director, Office of Management and Budget.
[FR Doc. 01-31663 Filed 12-21-01; 8:45 am]
BILLING CODE 3110-01-P