[Federal Register Volume 65, Number 211 (Tuesday, October 31, 2000)]
[Notices]
[Pages 65024-65032]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-27726]


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

1. Department of Defense

    The FY 2001 Department of Defense (DoD) reimbursement rates for 
inpatient, outpatient, and other services are provided in accordance 
with Title 10, United States Code, section 1095. Due to size, the 
sections containing the Drug Reimbursement Rates (section IV.C.) and 
the rates for Ancillary Services Requested by Outside Providers 
(section IV.D.) are not included in this package. Those rates are 
available from the TRICARE Management Activity's Uniform Business 
Office website, http://www.tricare.osd.mil/ebc/rm/rm__home.html. The 
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, 2000. Pharmacy rates are updated on 
an as needed basis.

2. Health and Human Services

    The FY 2001 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

[[Page 65025]]

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. 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, 2000 and 
thereafter:

Inpatient, Outpatient and Other Rates and Charges

1. Inpatient Rates<INF>12</INF>

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

Average FY01 Direct Care Inpatient Reimbursement Rates

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

2. Overview

    The FY01 inpatient rates are based on the cost per DRG, which is 
the inpatient full reimbursement rate per hospital discharge weighted 
to reflect the intensity of the principal diagnosis, secondary 
diagnoses, procedures, patient age, etc. involved. The average cost per 
Relative Weighted Product (RWP) for large urban, other urban/rural, and 
overseas facilities will be published annually as an inpatient adjusted 
standardized amount (ASA) (see paragraph I.C.1., above). The ASA will 
be applied to the RWP for each inpatient case, determined from the DRG 
weights, outlier thresholds, and payment rules published annually for 
hospital reimbursement rates under the Civilian Health and Medical 
Program of the Uniformed Services (CHAMPUS) pursuant to 32 CFR 
199.14(a)(1), including adjustments for length of stay (LOS) outliers. 
Each large urban or other urban/rural MTF providing inpatient care has 
their own ASA rate--The MTF-specific ASA rate is the published ASA rate 
adjusted for area wage differences and indirect medical education (IME) 
for the discharging hospital (see Attachment 1). The MTF-specific ASA 
rate submitted on the claim is the rate that payers will use for 
reimbursement purposes. For a more complete description of the 
development of MTF-ASAs and how they are applied refer to the ASA 
Primer at http://www.tricare.osd.mil/org/pae/asa--primer/asa--
primer1.html.
    Overseas MTFs use the rates specified in paragraph I. C. 1. For 
providers performing inpatient care at a civilian facility for a DoD 
beneficiary, see note 3. An example of how to apply DoD costs to a DRG 
standardized weight to arrive at DoD costs is contained in paragraph 
I.C.3., below.

3. Example of Adjusted Standardized Amounts for Inpatient Stays

    Figure 1 shows examples for a non-teaching hospital (Reynolds Army 
Community Hospital) in an Other Urban/Rural area.
    a. The cost to be recovered is the military treatment facility'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 2.2244. (DRG statistics 
shown are from FY 1999.)
    c. The MTF-applied ASA rate is $6,831 (Reynolds Army Community 
Hospital's third party rate as shown in Attachment 1).
    d. The MTF cost to be recovered is the RWP factor (2.2244) in 
subparagraph 3.b., above, multiplied by the amount ($6,831) in 
subparagraph 3.c., above.
    e. Cost to be recovered is $15,195.

[[Page 65026]]



                                                         Figure 1.--Third Party Billing Examples
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                      Arithmetic    Geometric    Short stay   Long stay
               DRG number                               DRG description                 DRG weight     mean LOS      mean LOS    threshold    threshold
--------------------------------------------------------------------------------------------------------------------------------------------------------
 020...................................  Nervous System Infection Except Viral              2.2244           8.3          5.8            1           29
                                          Meningitis.
--------------------------------------------------------------------------------------------------------------------------------------------------------


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


----------------------------------------------------------------------------------------------------------------
                                           Length of                  Relative weighted product
                 Patient                     stay     Days above -----------------------------------     TPC
                                            (days)     threshold  Inlier\*\  Outlier\**\    Total    Amount\***\
----------------------------------------------------------------------------------------------------------------
 #1.....................................           7           0     2.2244          000     2.2244     $15,195
 #2.....................................          21           0     2.2244          000     2.2244     $15,195
 #3.....................................          35           6     2.2244        .7594     2.9838    $20,382
----------------------------------------------------------------------------------------------------------------
\*\ DRG Weight
\**\ Outlier calculation = 33 percent of per diem weight  x  number of outlier days
= .33 (DRG Weight/Geometric Mean LOS)  x  (Patient LOS--Long Stay Threshold)
= .33 (2.2244/5.8)  x  (35-29)
= .33 (.38352)  x  6 (take out to five decimal places)
= .12656  x  6 (carry to five decimal places)
= .7594 (carry to four decimal places)
\***\ MTF-Applied ASA  x  Total RWP


                                              II. Outpatient Rates
                                                 [Per Visit <SUP>1,2</SUP>]
----------------------------------------------------------------------------------------------------------------
                                                                                Interagency and
                                                                International    other federal
       MEPRS code \4\                 Clinical service             military          agency       Other  (full/
                                                                education and      sponsored       third party)
                                                               training (IMET)      patients
----------------------------------------------------------------------------------------------------------------
                               A. Medical Care:
 BAA........................  Internal Medicine..............          $147.00          $204.00          $216.00
 BAB........................  Allergy........................            80.00           111.00           117.00
 BAC........................  Cardiology.....................           129.00           180.00           190.00
 BAE........................  Diabetic.......................           105.00           146.00           154.00
 BAF........................  Endocrinology (Metabolism).....           151.00           210.00           222.00
 BAG........................  Gastroenterology...............           183.00           255.00           269.00
 BAH........................   Hematology....................           286.00           398.00           420.00
 BAI........................   Hypertension..................           216.00           301.00           318.00
 BAJ........................   Nephrology....................           221.00           307.00           324.00
 BAK........................   Neurology.....................           165.00           229.00           242.00
 BAL........................   Outpatient Nutrition..........            69.00            96.00           101.00
 BAM........................   Oncology......................           201.00           280.00           295.00
 BAN........................   Pulmonary Disease.............           186.00           259.00           273.00
 BAO........................   Rheumatology..................           139.00           194.00           205.00
 BAP........................   Dermatology...................           115.00           160.00           169.00
 BAQ........................   Infectious Disease............           181.00           252.00           266.00
 BAR........................   Physical Medicine.............           115.00           160.00           169.00
 BAS........................   Radiation Therapy.............           169.00           235.00           248.00
 BAT........................   Bone Marrow Transplant........           190.00           264.00           279.00
 BAU........................   Genetic.......................           330.00           460.00           485.00
 BAV........................   Hyperbaric....................           344.00           480.00           506.00
                               B. Surgical Care:
 BBA........................   General Surgery...............           215.00           299.00           316.00
 BBB........................   Cardiovascular and Thoracic              419.00           584.00           616.00
                               Surgery.
 BBC........................  Neurosurgery...................           249.00           347.00           366.00
 BBD........................   Ophthalmology.................           130.00           181.00           191.00
 BBE........................   Organ Transplant..............         1,106.00         1,541.00         1,625.00
 BBF........................   Otolaryngology................           149.00           207.00           219.00
 BBG........................   Plastic Surgery...............           168.00           235.00           247.00
 BBH........................   Proctology....................           125.00           174.00           184.00
 BBI........................   Urology.......................           164.00           228.00           240.00
 BBJ........................   Pediatric Surgery.............            89.00           125.00           131.00
 BBK........................   Peripheral Vascular Surgery...            98.00           137.00           145.00
 BBL........................   Pain Management...............           138.00           193.00           203.00
 BBM........................   Vascular and Interventional              493.00           687.00           724.00
                               Radiology.
                               C. Obstetrical and
                               Gynecological (OB-GYN) Care:
 BCA........................   Family Planning...............            76.00           106.00           111.00

[[Page 65027]]

 
 BCB........................   Gynecology....................           127.00           177.00           187.00
 BCC........................   Obstetrics....................           104.00           144.00           152.00
 BCD........................  Breast Cancer Clinic...........           240.00           334.00           352.00
                               D. Pediatric Care:
 BDA........................   Pediatric.....................            92.00           128.00           134.00
 BDB........................   Adolescent....................            83.00           115.00           121.00
 BDC........................   Well Baby.....................            63.00            87.00            92.00
                               E. Orthopaedic Care:
 BEA........................   Orthopaedic...................           143.00           200.00           211.00
 BEB........................   Cast..........................            89.00           123.00           130.00
 BEC........................   Hand Surgery..................            76.00           106.00           112.00
 BEE........................   Orthotic Laboratory...........            93.00           130.00           137.00
 BEF........................   Podiatry......................            80.00           112.00           118.00
 BEZ........................   Chiropractic..................            38.00            53.00            55.00
                               F. Psychiatric and/or Mental
                               Health Care:
 BFA........................  Psychiatry.....................           165.00           230.00           242.00
 BFB........................   Psychology....................           115.00           160.00           169.00
 BFC........................   Child Guidance................            92.00           128.00           135.00
 BFD........................   Mental Health.................           148.00           206.00           217.00
 BFE........................   Social Work...................           147.00           205.00           217.00
 BFF........................   Substance Abuse...............           141.00           197.00           208.00
                               G. Family Practice/Primary
                               Medical Care:
 BGA........................   Family Practice...............           107.00           149.00           157.00
 BHA........................   Primary Care..................           109.00           151.00           160.00
 BHB........................   Medical Examination...........           111.00           155.00           163.00
 BHC........................   Optometry.....................            72.00           100.00           105.00
 BHD........................   Audiology.....................            52.00            73.00            77.00
 BHE........................   Speech Pathology..............           122.00           170.00           180.00
 BHF........................   Community Health..............            85.00           118.00           125.00
 BHG........................   Occupational Health...........           108.00           151.00           159.00
 BHH........................   TRICARE Outpatient............            74.00           104.00           109.00
 BHI........................   Immediate Care................           161.00           225.00           237.00
                               H. Emergency Medical Care:
 BIA........................   Emergency Medical.............           173.00           242.00           255.00
                               I. Flight Medical Care:
 BJA........................   Flight Medicine...............           124.00           173.00           182.00
                               J. Underseas Medical Care:
 BKA........................   Underseas Medicine............            77.00           108.00           114.00
                               K. Rehabilitative Services:
 BLA........................   Physical Therapy..............            56.00            79.00            83.00
 BLB........................   Occupational Therapy..........            75.00           104.00           110.00
----------------------------------------------------------------------------------------------------------------


                                      III. Ambulatory Procedure Visit (APV)
                                                 [Per visit \5\]
----------------------------------------------------------------------------------------------------------------
                                                                                Interagency and
                                                                International    other federal
       MEPRS code \4\                 Clinical service             military          agency       Other  (full/
                                                                education and      sponsored       third party)
                                                               training (IMET)      patients
----------------------------------------------------------------------------------------------------------------
                              Medical Care:
BB..........................  Surgical Care..................        $1,313.00        $1,829.00        $1,929.00
BE..........................  Orthopaedic Care...............         1,664.00         2,319.00         2,446.00
All Other...................  B clinics other than BB and BE,           378.00           527.00           556.00
                               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 II.
                               Some B clinics, such as BF,
                               BI, BJ and BL, perform the
                               type of services where the
                               establishment of an APU would
                               not be within appropriate
                               clinical guidelines.
----------------------------------------------------------------------------------------------------------------


[[Page 65028]]


                                       IV. Other Rates and Charges \1\ \2\
----------------------------------------------------------------------------------------------------------------
                                                                                Interagency and
                                                                International    other federal
       MEPRS code \4\                 Clinical service             military          agency       Other  (full/
                                                                education and      sponsored       third party)
                                                               training (IMET)      patients
----------------------------------------------------------------------------------------------------------------
                              A. Per Each:
FBI.........................  Immunization...................           $22.00           $31.00           $32.00
                              B. Family Member Rate: $11.45
                               (formerly Military Dependents
                               Rate)
                              C. Reimbursement Rates For
                               Drugs Requested By Outside
                               Providers: \6\ \15\
                              D. Ancillary Services Requested
                               by an Outside Provider--Per
                               Procedure: \7\ \15\
DB..........................  Laboratory procedures requested            15.00            22.00            23.00
                               by an outside provider CPT '00
                               Weight Multiplier.
DC, DI......................  Radiology procedures requested             79.00           115.00           120.00
                               by an outside provider CPT '00
                               Weight Multiplier.
                              E. Dental Rate--Per Procedure:
                               \11\
                              Dental Services ADA code weight            73.00           112.00           117.00
                               multiplier.
                              F. Ambulance Rate--Per Hour:
                               \12\
FEA.........................  Ambulance......................            81.00           113.00           120.00
                              G. AirEvac Rate--Per Trip (24
                               hour period): \13\
                              AirEvac Services--Ambulatory              339.00           473.00           499.00
                              AirEvac Services--Litter.......           989.00         1,379.00         1,454.00
                              H. Observation Rate--Per hour--
                               \14\
                              Observation Services--Hour.....            20.00            28.00            30.00
----------------------------------------------------------------------------------------------------------------


                                V. Elective Cosmetic Surgery Procedures and Rates
----------------------------------------------------------------------------------------------------------------
                                       International       Current
                                       classification     procedural
     Cosmetic surgery procedure       diseases  (ICD-    terminology      FY 2001 Charge \9\    Amount of charge
                                             9)           (CPT) \8\
----------------------------------------------------------------------------------------------------------------
Mammaplasty--augmentation...........            85.50            19325  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                85.32            19324
                                                85.31            19318
Mastopexy...........................            85.60            19316  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Facial..............................            86.82            15824  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
Rhytidectomy........................            86.22
Blepharoplasty......................            08.70            15820  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
                                                08.44            15821
                                                                 15822
                                                                 15823
Mentoplasty (Augmentation/or                    76.68            21208  Inpatient Surgical                  (<SUP>a</SUP>)
 Reduction).                                                             Care Per Diem APV or               (<SUP>b</SUP>)
                                                                         applicable Outpatient              (<SUP>c</SUP>)
                                                                         Clinic Rate
                                                76.67            21209
Abdominoplasty......................            86.83            15831  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Lipectomy...........................            86.83            15876  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Suction per region 10...............                             15877
                                                                 15878
                                                                 15879
Rhinoplasty.........................            21.87            30400  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
                                                21.86            30410

[[Page 65029]]

 
Scar Revisions beyond CHAMPUS.......            86.84           1578__  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Mandibular or Maxillary                         76.41            21194  Inpatient Surgical                  (<SUP>a</SUP>)
 Repositioning.                                                          Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Dermabrasion........................            86.25            15780  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Hair Restoration....................            86.64            15775  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Removing Tattoos....................            86.25            15780  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Chemical Peel.......................            86.24            15790  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
Arm/Thigh: Dermolipectomy...........            86.83           15836/  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         APV or applicable                  (<SUP>b</SUP>)
                                                                         Outpatient Clinic                  (<SUP>c</SUP>)
                                                                         Rate                               (<SUP>e</SUP>)
Refractive surgery..................  ...............            15832
Radial Keratotomy...................  ...............            65771
    Other Procedure (if applies to    ...............            66999
     laser or other.
    refractive surgery).............
Otoplasty...........................  ...............            69300  APV or applicable                   (<SUP>b</SUP>)
                                                                         Outpatient Clinic                  (<SUP>c</SUP>)
                                                                         Rate
Brow Lift...........................             86.3            15839  Inpatient Surgical                  (<SUP>a</SUP>)
                                                                         Care Per Diem or APV               (<SUP>b</SUP>)
                                                                         or applicable                      (<SUP>c</SUP>)
                                                                         Outpatient Clinic
                                                                         Rate
----------------------------------------------------------------------------------------------------------------

Notes on Cosmetic Surgery Charges

    \a\ Per diem charges for inpatient surgical care services are 
listed in section I.B. (See notes 8 through 10, below, for further 
details on reimbursable rates.)
    \b\ Charges for ambulatory procedure visits (formerly same day 
surgery) are listed in section III. (See notes 8 through 10, below, 
for further details on reimbursable rates.) The ambulatory procedure 
visit (APV) rate is used if the elective cosmetic surgery is 
performed in an ambulatory procedure unit (APU).
    \c\ Charges for outpatient clinic visits are listed in sections 
II.A-K. The outpatient clinic rate is not used for services provided 
in an APU. The APV rate should be used in these cases.
    \d\ Charge is solely determined by the location of where the 
care is provided and is not to be based on any other criteria. An 
APV rate can only be billed if the location has been established as 
an APU following all required DoD guidelines and instructions.
    \e\ Refer to HA 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 98 percent hospital and 2 percent 
professional charges. The outpatient per visit percentages are 89 
percent outpatient services and 11 percent professional charges.
    \2\ DoD civilian employees located in overseas areas shall be 
rendered a bill when services are performed.
    \3\ The cost per Diagnosis Related Group (DRG) is based on the 
inpatient full reimbursement rate per hospital discharge, weighted 
to reflect the intensity of the principal and secondary diagnoses, 
surgical procedures, and patient demographics involved. The adjusted 
standardized amounts (ASA) per Relative Weighted Product (RWP) for 
use in the direct care system is comparable to procedures used by 
the Health Care Financing Administration (HCFA) and the Civilian 
Health and Medical Program for the Uniformed Services (CHAMPUS). 
These expenses include all direct care expenses associated with 
direct patient care. The average cost per RWP for large urban, other 
urban/rural, and overseas will be published annually as an adjusted 
standardized amount (ASA) and will include the cost of inpatient 
professional services. The DRG rates will apply to reimbursement 
from all sources, not just third party payers.
    MTFs without inpatient services, whose providers are performing 
inpatient care in a civilian facility for a DoD beneficiary, can 
bill payers the percentage of the charge that represents 
professional services as provided in \1\ above. The ASA rate used in 
these cases, based on the absence of a ASA rate for the facility, 
will be based on the average ASA rate for the type of metropolitan 
statistical area the MTF resides, large urban, other urban/rural, or 
overseas. (see paragraph I.C.1.). The Uniform Business Office must 
receive documentation of care provided in order to produce a bill.
    \4\ The Medical Expense and Performance Reporting System (MEPRS) 
code is a three

[[Page 65030]]

digit code which defines the summary account and the sub account 
within a functional category in the DoD medical system. MEPRS codes 
are used to ensure that consistent expense and operating performance 
data is reported in the DoD military medical system. An example of 
the MEPRS hierarchical arrangement follows:

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

    \5\ 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 can not be defined and an APV can not 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 a Military Treatment Facility 
(MTF) that are prescribed by providers external to the MTF (e.g., 
physicians and dentists). Eligible beneficiaries (family members or 
retirees with medical insurance) are not liable personally for this 
cost and shall not be billed by the MTF. Medical Services Account 
(MSA) patients, who are not beneficiaries as defined in 10 U.S.C. 
1074 and 1076, are charged at the ``Other'' rate if they are seen by 
an outside provider and only come to the MTF for prescription 
services. The standard cost of medications ordered by an outside 
provider includes the DoD-wide average cost of the drug, calculated 
by National Drug Code (NDC) number. The prescription charge is 
calculated by multiplying the number of units (e.g., tablets or 
capsules) by the unit cost and adding $6.00 for the cost of 
dispensing the prescription. Dispensing costs include overhead, 
supplies and labor, etc. to fill the prescription.
    The list of drug reimbursement rates is too large to include in 
this document. Those rates are available from the TRICARE Management 
Activity's Uniform Business Office website, http://
www.tricare.osd.mil/ebc/rm/rm__home.html.
    \7\ The list of FY 2001 rates for ancillary services requested 
by outside providers and obtained at a 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/rm__home.html.
    Charges for ancillary services requested by an outside provider 
(e.g., physicians and dentists) are relevant to the Third Party 
Collection Program. Third party payers (such as insurance companies) 
shall be billed for ancillary services when beneficiaries who have 
medical insurance obtain services from the MTF which are prescribed 
by providers external to the MTF. Laboratory and Radiology procedure 
costs are calculated by multiplying the DoD established weight for 
the Physicians' Current Procedural Terminology (CPT 00) code by 
either the laboratory or radiology multiplier (section IV.D.). 
Radiology procedures performed by Nuclear Medicine use the same 
methodology as Radiology for calculating a charge because their 
workload and expenses are included in the establishment of the 
Radiology multiplier.
    Eligible beneficiaries (family members or retirees with medical 
insurance) are not personally liable for this cost and shall not be 
billed by the MTF. MSA patients, who are not beneficiaries as 
defined by 10 U.S.C. 1074 and 1076, are charged at the ``Other'' 
rate if they are seen by an outside provider and only come to the 
MTF for ancillary services.
    \8\ The attending physician is to complete the CPT 00 code to 
indicate the appropriate procedure followed during cosmetic surgery. 
The appropriate rate will be applied depending on the treatment 
modality of the patient: ambulatory procedure visit, outpatient 
clinic visit or inpatient surgical care services.
    \9\ Family members of active duty personnel, retirees and their 
family members, and survivors shall be charged elective cosmetic 
surgery rates. Elective cosmetic surgery procedure information is 
contained in section V. The patient shall be charged the rate as 
specified in the FY 2001 reimbursable rates for an episode of care. 
The charges for elective cosmetic surgery are at the full 
reimbursement rate (designated as the ``Other'' rate) for inpatient 
per diem surgical care services in section I.B., ambulatory 
procedure visits as contained in section III., or the appropriate 
outpatient clinic rate in sections II.A-K. The patient is 
responsible for the cost of the implant(s) and the prescribed 
cosmetic surgery rate. (Note: The implants and procedures used for 
the augmentation mammaplasty are in compliance with Federal Drug 
Administration guidelines.)
    \10\ Each regional lipectomy shall carry a separate charge. 
Regions include head and neck, abdomen, flanks, and hips.
    \11\ Dental service rates are based on a dental rate multiplied 
by the DoD established weight for the American Dental Association 
(ADA) code performed. For example, for ADA code 00270, bite wing 
single film, the weight is 0.15. The weight of 0.15 is multiplied by 
the appropriate rate, IMET, IAR, or Full/Third Party rate to obtain 
the charge. If the Full/Third Party rate is used, then the charge 
for this ADA code will be $17.55 ($117  x  .15 = $17.55).
    The list of FY 2001 ADA codes and weights for dental services is 
too large to include in this document. Those rates are available 
from the TRICARE Management Activity's Uniform Business Office 
website, http://www.tricare.osd.mil/ebc/rm/rm_home.html.
    \12\ Ambulance charges shall be based on hours of service in 15 
minute increments. The rates listed in section IV.F. are for 60 
minutes or 1 hour of service. Providers shall calculate the charges 
based on the number of hours (and/or fractions of an hour) that the 
ambulance is logged out on a patient run. Fractions of an hour shall 
be rounded to the next 15 minute increment (e.g., 31 minutes shall 
be charged as 45 minutes).
    \13\ Air in-flight medical care reimbursement charges are 
determined by the status of the patient (ambulatory or litter) and 
are per patient during a 24 hour period. The appropriate charges are 
billed only by the Air Force Global Patient Movement Requirement 
Center (GPMRC). These charges are only for the cost of providing 
medical care. Flight charges are billed by GPMRC separately.
    \14\ Observation Services are billed at the hourly charge. Begin 
counting when the patient is placed in the observation bed and round 
to the nearest hour. For example, if a patient has received one hour 
and 20 minutes of observation, then you bill for one hour of 
service. If the status of a patient changes to inpatient, the 
charges for observation services are added to the DRG assigned to 
the case and not separately billed. If a patient is released from 
observation status and is sent to an APV, the charges for 
observation services are not billed separately but are added to the 
APV rate to recover all expenses.
    \15\ Final rule 32 CFR part 220, published February 16, 2000, 
eliminated the dollar threshold for high cost ancillary services and 
the associated term ``high cost ancillary service.'' The phrase 
``high cost ancillary service'' is replaced with the phrase 
``ancillary services requested by an outside provider.'' The 
elimination of the threshold also eliminated the need to bundle 
costs whereby a patient is billed if the total cost of ancillary 
services in a day (defined as 0001 hours to 2400 hours) exceeds 
$25.00. The elimination of the threshold is effective as per date 
stated in final rule 32 CFR Part 220.

[[Page 65031]]



                Attachment 1.--Adjusted Standardized Amounts (ASA) By Military Treatment Facility
----------------------------------------------------------------------------------------------------------------
                                                                        Full cost  Interagency    IMET     TPC
       DMISID                    MTF name                   Serv          rate         rate       rate     rate
----------------------------------------------------------------------------------------------------------------
0003................  Lyster AH--Ft. Rucker.........  A..............      $6,637       $6,286   $3,286   $6,637
0004................  502nd Med Grp--Maxwell AFB....  F..............       6,984        6,614    3,458    6,984
0005................  Bassett ACH--Ft. Wainwright...  A..............       7,152        6,774    3,541    7,152
0006................  3rd Med Grp--Elmendorf AFB....  F..............       7,041        6,668    3,486    7,041
0009................  56th Med Grp--Luke AFB........  F..............       5,986        5,697    2,978    5,986
0014................  60th Med Grp--Travis AFB......  F..............       9,912        9,387    4,907    9,912
0018................  30th Med Grp--Vandenberg AFB..  F..............       7,035        6,663    3,483    7,035
0019................  95th Med Grp--Edwards AFB.....  F..............       7,004        6,633    3,468    7,004
0024................  NH Camp Pendleton.............  N..............       7,614        7,245    3,787    7,614
0028................  NH Lemoore....................  N..............       6,997        6,627    3,465    6,997
0029................  NH San Diego..................  N..............       9,744        9,273    4,847    9,744
0030................  NH Twenty Nine Palms..........  N..............       6,111        5,815    3,039    6,111
0032................  Evans ACH--Ft. Carson.........  A..............       6,946        6,578    3,439    6,946
0033................  10th Med Grp--USAF Academy....  F..............       6,994        6,623    3,463    6,994
0037................  Walter Reed AMC-- Washington    A..............       9,010        8,574    4,482    9,010
                       DC.
0038................  NH Pensacola..................  N..............       8,939        8,465    4,426    8,939
0039................  NH Jacksonville...............  N..............       7,537        7,173    3,749    7,537
0042................  96th Med Grp--Eglin AFB.......  F..............       8,309        7,869    4,114    8,309
0043................  325th Med Grp--Tyndall AFB....  F..............       7,002        6,631    3,467    7,002
0045................  6th Med Grp--MacDill AFB......  F..............       5,991        5,702    2,980    5,991
0047................  Eisenhower AMC--Ft. Gordon....  A..............       8,550        8,098    4,233    8,550
0048................  Martin ACH--Ft. Benning.......  A..............       7,987        7,564    3,954    7,987
0049................  Winn ACH--Ft. Stewart.........  A..............       6,644        6,292    3,289    6,644
0052................  Tripler AMC--Ft. Shafter......  A..............       9,533        9,029    4,720    9,533
0053................  366th Med Grp--Mountain Home    F..............       6,982        6,612    3,457    6,982
                       AFB.
0055................  375th Med Grp--Scott AFB......  F..............       7,625        7,256    3,793    7,625
0056................  NH Great Lakes................  N..............       6,063        5,770    3,016    6,063
0057................  Irwin AH--Ft. Riley...........  A..............       6,521        6,176    3,229    6,521
0060................  Blanchfield ACH--Ft. Campbell.  A..............       6,605        6,255    3,270    6,605
0061................  Ireland ACH--Ft. Knox.........  A..............       6,829        6,467    3,381    6,829
0064................  Bayne-Jones ACH--Ft. Polk.....  A..............       6,573        6,225    3,254    6,573
0066................  89th Med Grp--Andrews AFB.....  F..............       8,062        7,672    4,010    8,062
0067................  NNMC Bethesda.................  N..............       9,786        9,313    4,868    9,786
0073................  81st Med Grp--Keesler AFB.....  F..............       8,772        8,308    4,343    8,772
0075................  Wood ACH--Ft. Leonard Wood....  A..............       6,539        6,193    3,237    6,539
0078................  55th Med Grp--Offutt AFB......  F..............       8,697        8,236    4,306    8,697
0079................  99th Med Grp--Nellis AFB......  F..............       6,002        5,712    2,986    6,002
0083................  377th Med Grp--Kirtland AFB...  F..............       6,971        6,602    3,452    6,971
0084................   49th Med Grp--Holloman AFB...  F..............       7,004        6,633    3,468    7,004
0086................  Keller ACH--West Point........  A..............       7,296        6,909    3,612    7,296
0089................  Womack AMC--Ft. Bragg.........  A..............       7,817        7,403    3,870    7,817
0091................  NH Camp LeJeune...............  N..............       6,744        6,387    3,339    6,744
0092................  NH Cherry Point...............  N..............       6,788        6,429    3,361    6,788
0093................   319th Med Grp--Grand Forks     F..............       7,032        6,660    3,482    7,032
                       AFB.
0094................  5th Med Grp--Minot AFB........  F..............       6,857        6,494    3,395    6,857
0095................   74th Med Grp--Wright-           F.............      10,371        9,822    5,135   10,371
                       Patterson AFB.
0096................  72nd Med Grp--Tinker AFB......  F..............       6,001        5,711    2,985    6,001
0097................  97th Med Grp--Altus AFB.......  F..............       6,976        6,607    3,454    6,976
0098................  Reynolds ACH--Ft. Sill........  A..............       6,831        6,469    3,382    6,831
0100................  NH Newport....................  N..............       6,002        5,712    2,986    6,002
0101................  20th Med Grp--Shaw AFB........  F..............       6,964        6,595    3,448    6,964
0103................  NH Charleston.................  N..............       6,879        6,514    3,406    6,879
0104................  NH Beaufort...................  N..............       6,871        6,507    3,402    6,871
0105................  Moncrief ACH--Ft. Jackson.....  A..............       6,961        6,592    3,446    6,961
0106................  28th Med Grp--Ellsworth AFB...  F..............       6,939        6,572    3,436    6,939
0108................  Wm Beaumont AMC--Ft. Bliss....  A..............       8,329        7,888    4,124    8,329
0109................   Brooke AMC--Ft. Sam Houston..  A..............       8,511        8,099    4,233    8,511
0110................  Darnall AH--Ft. Hood..........  A..............       8,606        8,151    4,261    8,606
0112................  7th Med Grp--Dyess AFB........  F..............       6,892        6,528    3,413    6,892
0113................  82nd Med Grp--Sheppard AFB....  F..............       6,903        6,537    3,418    6,903
0117................  59th Med Wing--Lackland AFB...  F..............       8,640        8,222    4,297    8,640
0119................  75th Med Grp--Hill AFB........  F..............       5,983        5,693    2,976    5,983
0120................  1st Med Grp--Langley AFB......  F..............       5,954        5,666    2,962    5,954
0121................  McDonald ACH--Ft. Eustis......  A..............       5,649        5,376    2,810    5,649
0123................  Dewitt AH--Ft. Belvoir........  A..............       8,237        7,839    4,097    8,237
0124................  NH Portsmouth.................  N..............       7,469        7,107    3,715    7,469
0125................  Madigan AMC--Ft. Lewis........  A..............      11,018       10,435    5,455   11,018
0126................  NH Bremerton..................  N..............       8,165        7,733    4,043    8,165
0127................  NH Oak Harbor.................  N..............       6,283        5,979    3,125    6,283
0129................  90th Med Grp--F.E. Warren AFB.  F..............       6,989        6,619    3,460    6,989

[[Page 65032]]

 
0131................  Weed ACH--Ft. Irwin...........  A..............       7,003        6,633    3,467    7,003
0449................  24th Med Grp--Howard..........  F..............       9,489        9,045    3,872    9,489
0606................  95th CSH--Heidelberg..........  A..............       9,489        9,045    3,872    9,489
0607................  Landstuhl Rgn MC..............  A..............       9,489        9,045    3,872    9,489
0609................  67th CSH--Wurzburg............  A..............       9,489        9,045    3,872    9,489
0612................  121st Gen Hosp--Seoul.........  A..............       9,489        9,045    3,872    9,489
0615................  NH Guantanamo Bay.............  N..............       9,489        9,045    3,872    9,489
0616................  NH Roosevelt Roads............  N..............       9,489        9,045    3,872    9,489
0617................  NH Naples.....................  N..............       9,489        9,045    3,872    9,489
0618................  NH Rota.......................  N..............       9,489        9,045    3,872    9,489
0620................  NH Guam.......................  N..............       9,489        9,045    3,872    9,489
0621................  NH Okinawa....................  N..............       9,489        9,045    3,872    9,489
0622................  NH Yokosuka...................  N..............       9,489        9,045    3,872    9,489
0623................  NH Keflavik...................  N..............       9,489        9,045    3,872    9,489
0624................  BH Sigonella..................  N..............       9,489        9,045    3,872    9,489
0633................  48th Med Grp--RAF Lakenheath..  F..............       9,489        9,045    3,872    9,489
0635................  39th Med Grp--Incirlik AB.....  F..............       9,489        9,045    3,872    9,489
0638................  51st Med Grp--Osan AB.........  F..............       9,489        9,045    3,872    9,489
0639................  35th Med Grp--Misawa..........  F..............       9,489        9,045    3,872    9,489
0640................  374th Med Grp--Yokota AB......  F..............       9,489        9,045    3,872    9,489
0805................  52nd Med Grp--Spangdahlem.....  F..............       9,489        9,045    3,872    9,489
0808................  31st Med Grp--Aviano..........  F..............       9,489        9,045    3,872    9,489
----------------------------------------------------------------------------------------------------------------

2. Department of Health and Human Services

    For the Department of Health and Human Services, Indian Health 
Service, effective October 1, 2000 and thereafter:

Hospital Care Inpatient Day

General Medical Care
Alaska--$1,837
Rest of the United States--$1,357

Outpatient Medical Treatment

Outpatient Visit
Alaska--$337
Rest of the United States--$189

    For the period beginning October 1, 2000, the rates prescribed 
herein superceded those established by the Director of the Office of 
Management and Budget, November 1, 1999 (64 FR 58862).

Jacob J. Lew,
Director, Office of Management and Budget.
[FR Doc. 00-27726 Filed 10-30-00; 8:45 am]
BILLING CODE 3110-01-P