[Federal Register Volume 68, Number 211 (Friday, October 31, 2003)]
[Notices]
[Pages 62104-62109]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-27360]


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OFFICE OF MANAGEMENT AND BUDGET


Cost of Hospital and Medical Care Treatment Furnished by the 
United States; Certain Rates Regarding Recovery From Tortiously Liable 
Third Persons

    By virtue of the authority vested in the President by Section 2(a) 
of Pub. L. 87-693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to the 
Director of the Office of Management and Budget by Executive Order No. 
11541 of July 1, 1970 (35 Federal Register 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 the 
Department of Veterans Affairs and the Indian Health Service in the 
Department of Health and Human Services that were published in the 
Federal Register on October 31, 2000 and December 26, 2001, 
respectively, remain in effect until further notice. In addition, the 
inpatient rates for the Department of Defense published in on December 
9, 2002 remain in effect until further notice. The rates are as 
follows:

1. Department of Defense

    The Fiscal Year (FY) and Calendar Year (CY) 2003 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 Civilian Health 
and Medical Program of the Uniformed Services (CHAMPUS) Maximum 
Allowable Charges (CMAC, section II), Dental (section III. F), Pharmacy 
(section III. D), and Durable Medical Equipment/Durable Medical 
Supplies (DME/DMS) (section III. K) are not included in this package. 
Those rates are available from the TRICARE Management Activity (TMA) 
Uniform Business Office (UBO) Web site: http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm.
    The outpatient rates in this package will have an effective date of 
May 1, 2003. The inpatient medical rates in this package, republished 
in this package, are from the December 9, 2002 package and are 
referenced above on the UBO Web site; these became effective October 1, 
2002.
    A government billing calculation factor (percentage discount) for 
billing outpatient International Military Education and Training (IMET) 
(58.57% of full rate), and Interagency and Other Federal Agency 
Sponsored Patients (IAR) rate (93.14% of full rate), will be applied to 
the line item charges calculated for outpatient medical and ancillary 
services using CMAC or anesthesia charges.

Inpatient, Outpatient, and Other Rates and Charges

I. Inpatient Rates

A. All Inpatient Services

    (Based on Diagnosis Related Groups (DRG) \1\ \2\)
1. Average FY 2003 Direct Care Inpatient Reimbursement Rates

------------------------------------------------------------------------
                                                 Interagency
                                  International   and other      Other
                                     military      federal      (full/
 Adjusted standard amount (ASA)    education &      agency       third
                                     training     sponsored     party)
                                      (IMET)       patients
------------------------------------------------------------------------
Large Urban.....................     $3,521.00     $6,434.00   $6,748.00
Other Urban/Rural...............      4,316.00      7,191.00    7,575.00
Overseas........................      4,443.00      9,879.00   10,344.00
------------------------------------------------------------------------

2. Overview
    The FY 2003 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.A.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 CHAMPUS pursuant to 32 CFR 
199.14(a)(1), including adjustments for length of stay (LOS) outliers. 
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

[[Page 62105]]

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.A.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 an Other Urban/Rural area.
    a. The cost to be recovered is the MTF's 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 2.1159. (DRG statistics 
shown are from FY 2002.)
    c. The FY 2003 MTF-applied ASA rate is $7,152.00 (Reynolds Army 
Community Hospital's third party rate as shown in Attachment 1).
    d. The MTF cost to be recovered is the RWP factor (2.1159) in 
subparagraph 3.b., above, multiplied by the amount ($7,152.00) in 
subparagraph 3.c., above.
    e. Cost to be recovered is $15,134.00.

                                     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                2.1159          7.6          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.....        .8251          1.0    $7,575.00    $7,152.00
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                                                    Relative weighted product
           Patient              Length of stay    Days above ---------------------------------------  TPC amount
                                                  threshold     Inlier *    Outlier **     Total         ***
----------------------------------------------------------------------------------------------------------------
1...................  7 days..........            0       2.1159          000       2.1159   $15,134.00
2...................  21 days.........            0       2.1159          000       2.1159    15,134.00
3...................  35 days.........            6       2.1159        .7617       2.8776    20,581.00
----------------------------------------------------------------------------------------------------------------
* 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 (2.1159/5.5) x (35-29).
 =.33 (.38471) x 6 (extend to five decimal places).
 =.12695 x 6 (extend to five decimal places).
 =.7617 (extend to four decimal places).
*** MTF-Applied ASA x Total RWP.

II. Outpatient Rates \2\ \3\ \4\

    A. CMAC Rates. The CHAMPUS Maximum Allowable Charge (CMAC) rates, 
established under 32 CFR 199.14(h), are used for determining the 
appropriate charge for services in an itemized format, based on 
Healthcare Common Procedure Coding System (HCPCS) methodology. The CMAC 
rates are available on the TMA UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm. The 
CMAC rate tables contain the rates for radiology, laboratory, clinic 
procedures/services, and Evaluation and Management (E/M) Current 
Procedural Terminology (CPT) codes.
    CMAC is organized by 90 distinct ``localities,'' which account for 
differences in geographic regions based on demographics, cost of 
living, and population. Each MTF Defense Military Information System 
identification (DMIS ID) will map to a locality code to obtain the 
correct rates. For the complete DMIS ID locality table please refer to 
the DMIS ID Web site at http://www.dmisid.com/cgi-dmis/default.
    In each locality, there are three sub-tables of rates: CMAC, 
Component, and Non-CMAC. The CMAC rate table determines the payment for 
individual professional services and procedures identified CPT and 
HCPCS codes. The Component rate table is based on component rates 
comprising professional, technical and global rates. The Non-CMAC rate 
table captures pricing for procedure codes at the local or state level. 
Each state/locality does not have the same set of prevailing rates. 
When rates are pulled from the Non-CMAC table, the prevailing local fee 
is used in all cases.
    Within the CMAC tables, the rates are based not only on HCPCS but 
on a ``Provider Class'' based on medical specialty of the provider. 
Each provider is mapped to a provider class to calculate the correct 
rate.
    B. Per ClinicVisit. With implementation of OIB, an all-inclusive 
rate per clinic visit will no longer be charged. Instead, charges will 
be based on services provided and will be itemized.
    C. Ambulatory Procedure Visit (APV)--Per Visit \5\. APV charges are 
based on the CPT codes of the procedures performed. An itemized bill 
will be produced for the charges associated with the APV including 
ancillaries and anesthesia as applicable.

III. Other Rates and Charges

    A. Immunization The charge for immunizations, allergen extracts, 
allergic condition tests, and the administration of certain medications 
when these services are provided in a separate immunization or shot 
clinic, are based on CMAC rates in cases in which such rates are 
available. In cases in which such rates are not available, rates will 
be based on the average full cost of these services, exclusive of any 
costs considered for purposes of any outpatient visit. A separate 
charge shall be made for each immunization, injection or medication 
administered. If there is no CMAC rate available for an immunization or 
injection then the flat rate of $34.00 will be billed.
    B. Subsistence Rate \6\. The standard and discount rates for 
subsistence are available from the DoD Comptrollers Web site, Tab G: 
http://www.dod.mil/comptroller/ratesindex2003.html.
    C. Family Member Rate $12.72 (with exception of spouses and other

[[Page 62106]]

dependents of enlisted personnel in pay grades E-1 through E-4, who are 
charged the discount meal rate--See Comptrollers Web site, Tab G: 
http://www.dod.mil/comptroller/ratesindex2003.html.
    D. Pharmacy \7\. All medications, both internal and external, are 
billable. The rates for pharmacy are based on the average full cost of 
these drugs. These rates will be updated quarterly. These rates in this 
table are based on National Drug Code (NDC) codes. This rate table may 
be found on the TMA UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm.
    E. Ancillary Services. Per Procedure \8\. All Laboratory and 
Radiology procedures will be billed per CMAC Rates, including those 
associated with a clinic visit.
    F. Dental Rate--Per Procedure \9\.

----------------------------------------------------------------------------------------------------------------
                                                                                        Interagency
                                                                         International   and other
                                                                            military      Federal    Other (full/
             CDT/CPT                         Clinical service            education and     agency       third
                                                                            training     sponsored      party)
                                                                             (IMET)       patients
----------------------------------------------------------------------------------------------------------------
                                   Dental Services ADA code weight             $26.00        $60.00       $63.00
                                    multiplier.
----------------------------------------------------------------------------------------------------------------

    G. Ambulance Rate--Per Hour \10\.

----------------------------------------------------------------------------------------------------------------
                                                                                        Interagency
                                                                         International   and other
                                                                            military      Federal    Other (full/
             CDT/CPT                         Clinical service            education and     agency       third
                                                                            training     sponsored      party)
                                                                             (IMET)       patients
----------------------------------------------------------------------------------------------------------------
A0999............................  Ambulance...........................       $102.00       $140.00      $147.00
----------------------------------------------------------------------------------------------------------------

    H. AirEvac Rate--Per Trip (24-hour period) 11.

----------------------------------------------------------------------------------------------------------------
                                                                   International   Interagency &
                                                                     military      other Federal
                        Clinical Service                            education &       agency       Other (full/
                                                                     training        sponsored     third party)
                                                                      (IMET)         patients
----------------------------------------------------------------------------------------------------------------
AirEvac Services--Ambulatory....................................       $361.00         $494.00         $518.00
AirEvac Services--Litter........................................      1,047.00        1,435.00        1,503.00
----------------------------------------------------------------------------------------------------------------

    I. Observation Rate--Per Hour 12. Under OIB, observation 
services will be billed according to applicable CPT codes.
    J. Anesthesia The flat rate for anesthesia services is based on an 
average DoD cost of service in all MTFs. The range of HCPCS codes for 
anesthesia is 00100-01999. The flat rate for anesthesia will be 
$174.00.
    K. Durable Medical Equipment/Durable Medical Supplies (DME/DMS) 
Durable Medical Equipment (DME) and Durable Medical Supplies (DMS) are 
based on the Medicare Fee Schedule floor rate. The HCPCS codes 
contained in this table are for A4212-A7509, E0100-E2101, K0001-K0551, 
L0100-L8670, and V2020-V2780. This rate table may be found on the TMA 
UBO Web Site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm.

IV. Elective Cosmetic Surgery Procedures and Rates 13/

----------------------------------------------------------------------------------------------------------------
                                             Current procedural                                       Amount of
      Cosmetic surgery procedure             terminology (CPT)e              FY 2003 charge            charge
----------------------------------------------------------------------------------------------------------------
Abdominoplasty.......................  15831........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Blepharoplasty.......................  15820, 15821, 15822, 15823...  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Botox Injection for rhytids..........  J0585........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Brachioplasty........................  15836........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Brow Lift............................  15824, 15839.................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Buttock Lift.........................  15835........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Canthopexy...........................  21282, 67950.................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Cervicoplasty........................  15819........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Chemical Peel........................  15788, 15789, 15792, 15793...  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Collagen Injection, subcutaneous.....  11950, 11951, 11952, 11954...  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Dermabrasion.........................  15780, 15781, 15782, 15783...  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Arm/Thigh Dermolipectomy.............  15836, 15832.................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.

[[Page 62107]]

 
Excision/destruction of minor benign   11400, 11401, 11402, 11403,    Inpatient Charge per DRG or       (a b c)
 skin lesions.                          11404, 11406, 11420, 11421,    CPT.
                                        11422, 11423, 11424, 11426,
                                        11440, 11441, 11442, 11443,
                                        11444, 11446, 17000, 17003,
                                        17004, 17106, 17107, 17108,
                                        17110, 17111, 17250.
Facial Rhytidectomy..................  15824, 15825, 15826, 15828,    Inpatient Charge per DRG or       (a b c)
                                        15829.                         CPT.
Genioplasty..........................  21120, 21121.................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Hair Restoration.....................  15775, 15776.................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Hip Lift.............................  15834........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Laser Resurfacing....................  17999........................  Inpatient Charge per DRG or           (a)
                                                                       CPT.
Lipectomy Suction per region.........  15876, 15877, 15878, 15879...  Inpatient Charge per DRG or     (a b c f)
                                                                       CPT.
Malar Augmentation...................  21270........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Mammaplasty--augmentation............  19318, 19324, 19325,.........  Inpatient Charge per DRG or         (a b)
                                                                       CPT.
Mandibular or Maxillary Repositioning  21194........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Mastopexy............................  19316........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Mentoplasty (Augmentation/Reduction).  21208, 21209.................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Otoplasty............................  69300........................  Inpatient Charge per DRG or       (a b c)
                                                                       CPT.
Refractive surgery (see the following
 two procedures):
Radial Keratotomy....................  65771........................  CPT.........................      (b c d)
    Other Procedure (if applies to     66999........................  CPT.........................      (b c d)
     laser or other refractive
     surgery).
Rhinoplasty..........................  30400, 30410, 30430, 30435,    Inpatient Charge per DRG or       (a b c)
                                        30450, 30460, 30462.           CPT.
Scar Revisions beyond CHAMPUS........  13120, 13121, 13122, 13131,    Inpatient Charge per DRG or       (a b c)
                                        13132, 13133, 13150, 13152,    CPT.
                                        13153.
Sclerotherapy........................  36468, 36469, 36470, 36471,    Inpatient Charge per DRG or       (a b c)
                                        15780, 15781, 15782, 15783,    CPT.
                                        15786.
Tattoo Removal.......................  15780, 15783, 17999..........  Inpatient Charge per DRG or      (\a\ \b\
                                                                       CPT.                                \c\)
Thigh Lift...........................  15832........................  Inpatient Charge per DRG or      (\a\ \b\
                                                                       CPT.                                \c\)
Vein Stripping.......................  37720, 37730, 37735..........  Inpatient Charge per DRG or      (\a\ \b\
                                                                       CPT.                                \c\)
----------------------------------------------------------------------------------------------------------------
Notes on Cosmetic Surgery Charges:
\a\ Charges for Inpatient surgical care services are based on the cost per DRG.
\b\ Charges for outpatient surgical care services are based on the cost per CPT code.
\c\ All required DoD guidelines and instructions for APVs must be followed. An 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.
\d\ 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.
  The policy can be downloaded from: http://www.ha.osd.mil/policies/2000/00_003.pdf.
\e\ The attending physician is to document and record the appropriate DRG/CPT code to indicate the procedure
  followed during cosmetic surgery. It is up to the physician to decide whether or not the services are
  considered medically necessary or elective.
\f\ Each regional lipectomy shall carry a separate charge. Regions include head and neck, abdomen, flanks, and
  hips.

Notes on Reimbursable Rates

    \1\ 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 ASA per 
RWP for use in the direct care system is comparable to procedures 
used by the Centers for Medicare and Medicaid Services (CMS) and 
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 above. The ASA rate used in these 
cases, based on the absence of an 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.A.1.). The UBO must receive documentation 
of care provided in order to produce a bill.
    \2\ Percentages can be applied when preparing bills for 
inpatient services. Pursuant to the provisions of 10 U.S.C. 1095, 
the inpatient Diagnosis Related Groups percentages are 96 % hospital 
and 4% professional charges. When preparing bills for outpatient 
services, professional fees are based on the E/M charges, the 
hospital fees are based on the charges for ancillary services, 
pharmacy and supplies.
    \3\ The Medical Expense and Performance Reporting System (MEPRS) 
code is a three digit code which defines the summary account and the 
subaccount within a functional category in the DoD medical system. 
MEPRS codes are used to ensure that consistent expense and operating 
performance data is reported in the DoD military medical system. An 
example of the MEPRS hierarchical arrangement follows:

------------------------------------------------------------------------
                                                      MEPRS Code
------------------------------------------------------------------------
Outpatient Care (Functional Category)......  B
Medical Care (Summary Account).............  BA
Internal Medicine (Subaccount).............  BAA
------------------------------------------------------------------------

    \4\ The following chart of MEPRS work centers are DoD approved 
for outpatient itemized billing. Claims can be generated for 
encounters, ancillaries, pharmacy, DME/DMS, etc. from these 
workcenters.

------------------------------------------------------------------------
            MEPRS code                        Clinical service
------------------------------------------------------------------------
BAA                                 Internal Medicine.

[[Page 62108]]

 
BAB                                 Allergy.
BAC                                 Cardiology.
BAE                                 Diabetic.
BAF                                 Endocrinology (Metabolism).
BAG                                 Gastroenterology.
BAH                                 Hematology.
BAI                                 Hypertension.
BAJ                                 Nephrology.
BAK                                 Neurology.
BAL                                 Outpatient Nutrition.
BAM                                 Oncology.
BAN                                 Pulmonary Disease.
BAO                                 Rheumatology.
BAP                                 Dermatology.
BAQ                                 Infectious Disease.
BAR                                 Physical Medicine.
BAS                                 Radiation Therapy.
BAT                                 Bone Marrow Transplant.
BAU                                 Genetic.
BAV                                 Hyperbaric.
BBA                                 General Surgery.
BBB                                 Cardiovascular and Thoracic Surgery.
BBC                                 Neurosurgery.
BBD                                 Ophthalmology.
BBE                                 Organ Transplant.
BBF                                 Otolaryngology.
BBG                                 Plastic Surgery.
BBH                                 Proctology.
BBI                                 Urology.
BBJ                                 Pediatric Surgery.
BBK                                 Peripheral Vascular Surgery.
BBL                                 Pain Management.
BBM                                 Vascular and Interventional
                                     Radiology.
BCA                                 Family Planning.
BCB                                 Gynecology.
BCC                                 Obstetrics.
BCD                                 Breast Cancer Clinic.
BDA                                 Pediatric.
BDB                                 Adolescent.
BDC                                 Well Baby.
BEA                                 Orthopedic.
BEB                                 Cast.
BEC                                 Hand Surgery.
BEE                                 Orthotic Laboratory.
BEF                                 Podiatry.
BEZ                                 Chiropractic.
BFA                                 Psychiatry.
BFB                                 Psychology.
BFC                                 Child Guidance.
BFD                                 Mental Health.
BFE                                 Social Work.
BFF                                 Substance Abuse.
BGA                                 Family Practice.
BHA                                 Primary Care.
BHC                                 Optometry.
BHD                                 Audiology.
BHE                                 Speech Pathology.
BHF                                 Community Health.
BHG                                 Occupational Health.
BHH                                 TRICARE Outpatient.
BHI                                 Immediate Care.
BIA                                 Emergency Medical.
BKA                                 Underseas Medicine.
BLA                                 Physical Therapy.
BLB                                 Occupational Therapy.


------------------------------------------------------------------------
            MEPRS code                     Other billable services
------------------------------------------------------------------------
DAA                                 Pharmacy.
DBA                                 Clinical Pathology.
DBB                                 Anatomical Pathology.
DBD                                 Cytogenetic Laboratory.
DBE                                 Molecular Genetic Laboratory.
DBF                                 Biochemical Genetic Laboratory.
DCA                                 Diagnostic Radiology.
FBI                                 Immunizations.
FBN                                 Hearing Conservation (MSA Billing
                                     Only).
FC                                  Pharmacy, Laboratory and Radiology
                                     (External Civilian Ancillary and
                                     Support to other Military and
                                     Federal), except in cases where
                                     there is a specific VA/DoD MOU.
FEA                                 Ambulance.
------------------------------------------------------------------------

    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.
    6 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 UBO Manual, 
April 1997, and the DoD 7000.14-R, ``Department of Defense Financial 
Management Regulation,'' Volume 12, Chapter 19 for guidance on the 
use of these rates.
    7 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 both internal and 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 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 TMA's UBO Web 
site, http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm.
    8 Charges for ancillary services requested by an 
internal (associated with a clinic visit) or 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.
    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 not seen by an outside provider and only come to 
the MTF for ancillary services.
    9 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 $9.45 ($63 x .15 = $9.45).
    The list of CY 2003 ADA codes and weights for dental services is 
too large to include in this document. This rate table may be found 
on the TMA's UBO Web site at http://www.tricare.osd.mil/ebc/rm_home/ubo_documents_rates_tables.cfm.
    10 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).
    11 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.
    12 Observation Services are billed based on 
applicable CPTs. 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.
    13 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 CY 2003 reimbursable rates. The charges 
for elective

[[Page 62109]]

cosmetic surgery are at the full reimbursement rate (designated as 
the ``Other'' rate) for inpatient care services based on the cost 
per DRG or CPT. 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.)

            Attachment 1.--FY 2003 Adjusted Standardized Amounts (ASA) by Military Treatment Facility
----------------------------------------------------------------------------------------------------------------
      DMIS ID               MTF name               Serv        Full rate     IAR rate    IMET rate     TPC rate
----------------------------------------------------------------------------------------------------------------
0003...............  Lyster AH--Ft. Rucker.  A                     $7,032       $6,676       $4,007       $7,032
0005...............  Bassett ACH--Ft.        A                      7,794        7,399        4,441        7,794
                      Wainwright.
0006...............  3 Med Grp--Elmendorf    F                      7,624        7,237        4,344        7,624
                      AFB.
0009...............  56th Med Grp--Luke AFB  F                      6,734        6,421        3,514        6,734
0014...............  60th Med Grp--Travis    F                     10,529        9,995        6,000       10,529
                      AFB.
0024...............  NH Camp Pendleton.....  N                      8,189        7,808        4,274        8,189
0028...............  NH Lemoore............  N                      7,554        7,171        4,304        7,554
0029...............  NMC San Diego.........  N                     10,268        9,790        5,359       10,268
0030...............  NH Twentynine Palms...  N                      6,820        6,502        3,559        6,820
0032...............  Evans ACH--Ft. Carson.  A                      7,564        7,181        4,310        7,564
0033...............  10th Med Grp--USAF      F                      7,574        7,190        4,316        7,574
                      Academy.
0035...............  NH Groton.............  N                      7,575        7,191        4,316        7,575
0037...............  Walter Reed AMC--       A                     10,415        9,930        5,435       10,415
                      Washington DC.
0038...............  NH Pensacola..........  N                      9,119        8,656        5,196        9,119
0039...............  NH Jacksonville.......  N                      8,580        8,180        4,477        8,580
0042...............  96th Med Grp--Eglin     F                      9,580        9,095        5,459        9,580
                      AFB.
0045...............  6th Med Grp--MacDill    F                      6,748        6,434        3,521        6,748
                      AFB.
0047...............  Eisenhower AMC--Ft.     A                      9,312        8,839        5,306        9,312
                      Gordon.
0048...............  Martin ACH--Ft.         A                      8,315        7,893        4,738        8,315
                      Benning.
0049...............  Winn ACH--Ft. Stewart.  A                      7,564        7,180        4,310        7,564
0052...............  Tripler AMC--Ft.        A                     10,248        9,728        5,839       10,248
                      Shafter.
0053...............  366th Med Grp--Mtn      F                      7,560        7,176        4,308        7,560
                      Home AFB.
0055...............  375th Med Grp--Scott    F                      8,671        8,268        4,525        8,671
                      AFB.
0056...............  NH Great Lakes........  N                      6,802        6,486        3,550        6,802
0060...............  Blanchfield ACH--Ft.    A                      7,025        6,669        4,003        7,025
                      Campbell.
0061...............  Ireland ACH--Ft. Knox.  A                      6,620        6,311        3,454        6,620
0064...............  Bayne-Jones ACH--Ft.    A                      6,987        6,633        3,981        6,987
                      Polk.
0066...............  89th Med Grp--Andrews   F                      8,944        8,527        4,667        8,944
                      AFB.
0067...............  NNMC Bethesda.........  N                     10,397        9,913        5,426       10,397
0073...............  81st Med Grp--Keesler   F                     10,103        9,591        5,757       10,103
                      AFB.
0075...............  Wood ACH--Ft. Leonard   A                      7,179        6,815        4,091        7,179
                      Wood.
0078...............  55th Med Grp--Offutt    F                      9,972        9,466        5,682        9,972
                      AFB.
0079...............  99th Med Grp--Nellis    F                      6,763        6,448        3,529        6,763
                      AFB.
0086...............  Keller ACH--West Point  A                      8,234        7,816        4,692        8,234
0089...............  Womack AMC--Ft. Bragg.  A                      8,079        7,669        4,604        8,079
0091...............  NH Camp LeJeune.......  N                      7,352        6,980        4,190        7,352
----------------------------------------------------------------------------------------------------------------

    Beginning May 1, 2003, the rates prescribed herein superceded those 
established by the Director of the Office of Management and Budget, 
December 9, 2002 (FR Doc. 02-31024). 6

Joshua B. Bolten,
Director, Office of Management and Budget.
[FR Doc. 03-27360 Filed 10-30-03; 8:45 am]
BILLING CODE 3110-01-P