TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year 2010 Diagnosis Related Group (DRG) Updates, 50785-50787 [E9-23738]

Download as PDF Federal Register / Vol. 74, No. 189 / Thursday, October 1, 2009 / Notices service area sites will use a self-reported Health Risk Assessment (HRA) designed to screen and identify the participants’ health risk factors and provide targeted interventions that help prevent, manage, and improve chronic conditions. They will perform all of the study participants’ physiological and biometric measures, including at least blood pressure, glucose levels, lipids, nicotine use, and weight. The service area sites will schedule follow-up visits, encourage participants to take advantage of available online educational Web sites, and enroll in established wellness programs. They will also direct participants to retake the HRA/ biometrics annually to reassess health behaviors and outcomes. A toll-free phone line will be available to answer questions regarding enrollment and monetary incentives from demonstration participants. Dated: September 25, 2009. Patricia L. Toppings, OSD Federal Register Liaison Officer, Department of Defense. [FR Doc. E9–23741 Filed 9–30–09; 8:45 am] BILLING CODE 5001–06–P DEPARTMENT OF DEFENSE Office of the Secretary Renewal of Department of Defense Federal Advisory Committees Department of Defense (DoD). Renewal of Federal advisory committee. AGENCY: PWALKER on DSK8KYBLC1PROD with NOTICES ACTION: SUMMARY: Under the provisions of the Federal Advisory Committee Act of 1972, (5 U.S.C. Appendix, as amended), the Government in the Sunshine Act of 1976 (5 U.S.C. 552b, as amended), and 41 CFR 102–3.50, the Department of Defense gives notice that it is renewing the charter for the Defense Task Force on Sexual Assault in the Military Services (hereafter referred to as the Task Force). FOR FURTHER INFORMATION CONTACT: Jim Freeman, Deputy Committee Management Officer for the Department of Defense, 703–601–6128. SUPPLEMENTARY INFORMATION: The Task Force, pursuant to Section 576 of Public Law 108–375, is a non-discretionary Federal advisory committee established to conduct an examination of matters relating to sexual assault by members or against members of the Armed Forces of the United States. Pursuant to Section 576(e) of public Law 108–375, the Task Force, no later than one year after the initiation of its examination, shall submit to the VerDate Nov<24>2008 19:32 Sep 30, 2009 Jkt 217001 Secretary of Defense and the Secretaries of the Army, Navy and Air Force on the activities of the Department of Defense and the Armed Forces to respond to sexual assault. The Task Force shall be comprised of no more than ten members and the membership shall be comprised of an equal number of DoD and civilian members. The Secretary of Defense shall select the DoD Co-Chairperson, and the civilian members shall select a civilian Co-Chairperson. Task Force members who are appointed by the Secretary of Defense, who are not full-time or permanent parttime Federal employees, shall be appointed as experts and consultants under the authority of 5 U.S.C. 3109 and serve as Special Government Employees. All members shall be appointed on an annual basis for the duration of the Task Force. Task Force members who are Federal officers or employees shall serve without compensation (other than compensation to which they are entitled to as Federal officers or employees). Other Task Force members shall be appointed under the authority of 5 U.S.C 3161 and will receive compensation for their service. All Task Force members shall receive compensation for travel and per diem for official Task Force travel. With DoD approval, the Task Force is authorized to establish subcommittees, as necessary and consistent with its mission. These subcommittees or working groups shall operate under the provisions of the Federal Advisory Committee Act of 1972, the Government in the Sunshine Act of 1976 (5 U.S.C 552B, as amended), and other appropriate Federal regulations. Such subcommittees or workgroups shall not work independently of the chartered Task Force, and shall report all their recommendations and advice to the Task Force for full deliberation and discussion. Subcommittees or workgroups have no authority to make decisions on behalf of the chartered Task Force nor can they report directly to the Department of Defense or any Federal officers or employees who are not Task Force members. Subcommittee members, who are not Task Force members, shall be appointed in the same manner as the Task Force members. The Task Force shall meet at the call of the Task Force’s Designated Federal Officer, in consultation with the Chairperson. The estimated number of Task Force meetings is six per year. The Designated Federal Officer, pursuant to DoD policy, shall be a full- PO 00000 Frm 00024 Fmt 4703 Sfmt 4703 50785 time or permanent part-time DoD employee, and shall be appointed in accordance with established DoD policies and procedures. In addition, the Designated Federal Officer is required to be in attendance at all meetings, however, in the absence of the Designated Federal Officer, the Alternate Designated Federal Officer shall attend the meeting. Pursuant to 41 CFR 102–3.105(j) and 102–3.140, the public or interested organizations may submit written statements to the Defense Task Force on Sexual Assault in the Military Services membership about the Task Forces’ mission and functions. Written statements may be submitted at any time or in response to the stated agenda of planned meeting of the Defense Task Force on Sexual Assault in the Military Services. All written statements shall be submitted to the Designated Federal Officer for the Defense Task Force on Sexual Assault in the Military Services, and this individual will ensure that the written statements are provided to the membership for their consideration. Contact information for Defense Task Force on Sexual Assault in the Military Services’ Designated Federal Officer can be obtained from the GSA’s FACA Database—https://www.fido.gov/ facadatabase/public.asp. The Designated Federal Officer, pursuant to 41 CFR 102–3.150, will announce planned meetings of the Defense Task Force on Sexual Assault in the Military Services. The Designated Federal Officer, at that time, may provide additional guidance on the submission of written statements that are in response to the stated agenda for the planned meeting in question. Dated: September 28, 2009. Patricia L. Toppings, OSD Federal Register Liaison Officer, Department of Defense. [FR Doc. E9–23739 Filed 9–30–09; 8:45 am] BILLING CODE 5001–06–P DEPARTMENT OF DEFENSE Office of the Secretary TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year 2010 Diagnosis Related Group (DRG) Updates Office of the Secretary, DoD. Notice of DRG revised rates. AGENCY: ACTION: SUMMARY: This notice describes the changes made to the TRICARE DRGbased payment system in order to E:\FR\FM\01OCN1.SGM 01OCN1 50786 Federal Register / Vol. 74, No. 189 / Thursday, October 1, 2009 / Notices conform to changes made to the Medicare Prospective Payment System (PPS). It also provides the updated fixed loss cost outlier threshold, cost-tocharge ratios and the data necessary to update the Fiscal Year (FY) 2010 rates. DATES: The rates, weights, and Medicare PPS changes which affect the TRICARE DRG-based payment system contained in this notice are effective for admissions occurring on or after October 1, 2009. ADDRESSES: TRICARE Management Activity (TMA), Medical Benefits and Reimbursement Systems, 16401 East Centretech Parkway, Aurora, CO 80011– 9066. FOR FURTHER INFORMATION CONTACT: Ann N. Fazzini, Medical Benefits and Reimbursement Branch, TMA, telephone (303) 676–3803. Questions regarding payment of specific claims under the TRICARE DRG-based payment system should be addressed to the appropriate contractor. SUPPLEMENTARY INFORMATION: The final rule published on September 1, 1987 (52 FR 32992) set forth the basic procedures used under the CHAMPUS DRG-based payment system. This was subsequently amended by final rules published August 31, 1988 (53 FR 33461), October 21, 1988 (53 FR 41331), December 16, 1988 (53 FR 50515), May 30, 1990 (55 FR 21863), October 22, 1990 (55 FR 42560), and September 10, 1998 (63 FR 48439). An explicit tenet of these final rules, and one based on the statute authorizing the use of DRGs by TRICARE, is that the TRICARE DRG-based payment system is modeled on the Medicare PPS, and that, whenever practicable, the TRICARE system will follow the same rules that apply to the Medicare PPS. The Centers for Medicare and Medicaid Services (CMS) publishes these changes annually in the Federal Register and discusses in detail the impact of the changes. In addition, this notice updates the rates and weights in accordance with our previous final rules. The actual changes we are making, along with a description of their relationship to the Medicare PPS, are detailed below. PWALKER on DSK8KYBLC1PROD with NOTICES I. Medicare PPS Changes Which Affect the TRICARE DRG-Based Payment System Following is a discussion of the changes CMS has made to the Medicare PPS that affect the TRICARE DRG-based payment system. A. DRG Classifications Under both the Medicare PPS and the TRICARE DRG-based payment system, cases are classified into the appropriate VerDate Nov<24>2008 19:32 Sep 30, 2009 Jkt 217001 DRG by a Grouper program. The Grouper classifies each case into a DRG on the basis of the diagnosis and procedure codes and demographic information (that is, sex, age, and discharge status). The Grouper used for the TRICARE DRG-based payment system is the same as the current Medicare Grouper with two modifications. The TRICARE system has replaced Medicare DRG 435 with two age-based DRGs (900 and 901), and has implemented thirty-four (34) neonatal DRGs in place of Medicare DRGs 385 through 390. For admissions occurring on or after October 1, 2001, DRG 435 has been replaced by DRG 523. The TRICARE system has replaced DRG 523 with the two age-based DRGs (900 and 901). For admissions occurring on or after October 1, 1995, the CHAMPUS grouper hierarchy logic was changed so the age split (age <29 days) and assignments to Major Diagnostic Category (MDC) 15 occur before assignment of the PreMDC DRGs. This resulted in all neonate tracheostomies and organ transplants to be grouped to MDC 15 and not to DRGs 480–483 or 495. For admissions occurring on or after October 1, 1998, the CHAMPUS grouper hierarchy logic was changed to move DRG 103 to the PreMDC DRGs and to assign patients to PreMDC DRGs 480, 103 and 495 before assignment to MDC 15 DRGs and the neonatal DRGs. For admissions occurring on or after October 1, 2001, DRGs 512 and 513 were added to the PreMDC DRGs, between DRGs 480 and 103 in the TRICARE grouper hierarchy logic. For admissions occurring on or after October 1, 2004, DRG 483 was deleted and replaced with DRGs 541 and 542, splitting the assignment of cases on the basis of the performance of a major operating room procedure. The description for DRG 480 was changed to ‘‘Liver Transplant and/or Intestinal Transplant,’’ and the description for DRG 103 was changed to ‘‘Heart/Heart Lung Transplant or Implant of Heart Assist System.’’ For Fiscal Year 2007, CMS implemented classification changes, including surgical hierarchy changes. The TRICARE Grouper incorporated all changes made to the Medicare Grouper, with the exception of the pre-surgical hierarchy changes, which will remain the same as Fiscal Year 2006. For Fiscal Year 2008, Medicare implemented their MedicareSeverity DRG (MS–DRG) based payment system. TRICARE, however, continued with the Centers for Medicare and Medicaid Services DRG-based (CMS– DRG) payment system for Fiscal Year 2008. For Fiscal Year 2009, the PO 00000 Frm 00025 Fmt 4703 Sfmt 4703 TRICARE/CHAMPUS DRG-based payment system shall be modeled on the MS–DRG system, with the following modifications. The MS–DRG system consolidated the 43 pediatric CMS DRGs that were defined based on age less than or equal to 17 into the most clinically similar MS–DRGs. In their Inpatient Prospective Payment System final rule for MS– DRGs, Medicare stated for their population these pediatric CMS DRGs contained a very low volume of Medicare patients. At the same time, Medicare encouraged private insurers and other non-Medicare payers to make refinements to MS–DRGs to better suit the needs of the patients they serve. Consequently, TRICARE finds it appropriate to retain the pediatric CMS– DRGs for our population. TRICARE is also retaining the TRICARE-specific DRGs for neonates and substance use. TRICARE has retained the MS–DRG numbering system for Fiscal Year 2009, and those TRICARE-specific DRGs have been assigned available, blank DRG numbers unused in the MS–DRG system. We refer the reader to http:// www.tricare.mil/drgrates for a complete crosswalk containing the TRICARE DRG numbers for Fiscal Year 2009. For Fiscal Year 2009, TRICARE will use the MS–DRG v26.0 pre-MDC hierarchy, with the exception that MDC 15 is applied after DRG 011–012 and before MDC 24. For Fiscal Year 2010, there are no additional or deleted DRGs. B. Wage Index and Medicare Geographic Classification Review Board Guidelines TRICARE will continue to use the same wage index amounts used for the Medicare PPS. TRICARE will also duplicate all changes with regard to the wage index for specific hospitals that are redesignated by the Medicare Geographic Classification Review Board. In addition, TRICARE will continue to utilize the out commuting wage index adjustment. C. Revision of the Labor-Related Share of the Wage Index TRICARE is adopting CMS’ percentage of labor-related share of the standardized amount. For wage index values greater than 1.0, the labor-related portion of the Adjusted Standardized Amount (ASA) shall equal 68.8 percent. For wage-index values less than or equal to 1.0, the labor related portion of the ASA shall continue to equal 62 percent. D. Hospital Market Basket TRICARE will update the adjusted standardized amounts according to the E:\FR\FM\01OCN1.SGM 01OCN1 Federal Register / Vol. 74, No. 189 / Thursday, October 1, 2009 / Notices final updated hospital market basket used for the Medicare PPS for all hospitals subject to the TRICARE DRGbased payment system according to CMS’ August 27, 2009, final rule. For Fiscal Year 2010, the market basket is 2.1 percent. E. Outlier Payments Since TRICARE does not include capital payments in our DRG-based payments (TRICARE reimburses hospitals for their capital costs as reported annually to the contractor on a pass-through basis), we will use the fixed-loss cost-outlier threshold calculated by CMS for paying cost outliers in the absence of capital prospective payments. For Fiscal Year 2010, the fixed-loss cost-outlier threshold is based on the sum of the applicable DRG-based payment rate plus any amounts payable for Indirect Medical Education (IDME) plus a fixeddollar amount. Thus, for Fiscal Year 2010, in order for a case to qualify for cost outlier payments, the costs must exceed the TRICARE DRG base payment rate (wage adjusted) for the DRG plus the IDME payment plus $21,358 (wage adjusted). The marginal cost factor for cost outliers continues to be 80 percent. F. National Operating Standard Cost as a Share of Total Costs The Fiscal Year 2010 TRICARE National Operating Standard Cost as a Share of Total Costs (NOSCASTC) used in calculating the cost outlier threshold is 0.923. TRICARE uses the same methodology as CMS for calculating the NOSCASTC; however, the variables are different because TRICARE uses national cost to charge ratios while CMS uses hospital-specific cost-to-charge ratios. PWALKER on DSK8KYBLC1PROD with NOTICES G. Indirect Medical Education (IDME) Adjustment 19:32 Sep 30, 2009 Jkt 217001 For Fiscal Year 2010 TRICARE is adopting CMS’ expanded post-acutecare transfer policy according to CMS’ final rule published August 27, 2009. I. Blood Clotting Factor For Fiscal Year 2010, TRICARE is adopting CMS’ payment methodology for blood clotting factor according to CMS’ final rule published August 18, 2006. J. Cost-to-Charge Ratio While CMS uses hospital-specific cost-to-charge ratios, TRICARE uses a national cost-to-charge ratio. For Fiscal Year 2010, the cost-to-charge ratio used for the TRICARE DRG-based payment system for acute care hospitals and neonates will be 0.3740. This shall be used to calculate the adjusted standardized amounts and to calculate cost outlier payments, except for children’s hospitals. For children’s hospital cost outliers, the cost-to-charge ratio used is 0.4047. K. Updated Rates and Weights The updated rates and weights are accessible through the Internet at http:// www.tricare.osd.mil under the sequential headings TRICARE Provider Information, Rates and Reimbursements, and DRG Information. Table 1 provides the ASA rates and Table 2 provides the DRG weights to be used under the TRICARE DRG-based payment system during Fiscal Year 2010. The implementing regulations for the TRICARE/CHAMPUS DRG-based payment system are in 32 CFR part 199. Dated: September 25, 2009. Patricia L. Toppings, OSD Federal Register Liaison Officer, Department of Defense. [FR Doc. E9–23738 Filed 9–30–09; 8:45 am] BILLING CODE 5001–06–P Passage of the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003 modified the formula multipliers to be used in the calculation of the indirect medical education IDME adjustment factor. Since the IDME formula used by TRICARE does not include disproportionate share hospitals (DSHs), the variables in the formula are different than Medicare’s; however, the percentage reductions that will be applied to Medicare’s formula will also be applied to the TRICARE IDME formula. The new multiplier for the IDME adjustment factor for TRICARE for Fiscal Year 2010 is 1.02. VerDate Nov<24>2008 H. Expansion of the Post-Acute-Care Transfer Policy DEPARTMENT OF DEFENSE Department of the Army [Docket No. USA–2009–0018] Submission for OMB Review; Comment Request ACTION: Notice. The Department of Defense has submitted to OMB for clearance, the following proposal for collection of information under the provisions of the Paperwork Reduction Act (44 U.S.C. Chapter 35). PO 00000 Frm 00026 Fmt 4703 Sfmt 4703 50787 DATES: Consideration will be given to all comments received by November 2, 2009. Title, Form and OMB Number: Terminal and Transfer Facilities Descriptions, IWR Forms 1–9; OMB Control Number 0710–0007. Type of Request: Extension. Number of Respondents: 1,262. Responses per Respondent: 1. Annual Responses: 1,262. Average Burden per Response: 15 minutes. Annual Burden Hours: 316. Needs and Uses: Data gathered and published as one of the 56 Port Series Reports, relating to terminals, transfer facilities, storage facilities, and intermodal transportation. This information is used in navigation, planning, safety, National security, emergency operations, and general interest studies and activities. Respondents are terminal and transfer facility operators. These data are essential to the Waterborne Commerce Statistics Center in Exercising their enforcement and quality control responsibilities in the collection of data from vessel reporting companies. Affected Public: Business or other forprofit; Federal government; and State, Local or Tribal government. Frequency: Annually. Respondent’s Obligation: Voluntary. OMB Desk Officer: Mr. Jim Laity. Written comments and recommendations on the proposed information collection should be sent to Mr. Laity at the Office of Management and Budget, Desk Officer for DoD, Room 10236, New Executive Office Building, Washington, DC 20503. You may also submit comments, identified by docket number and title, by the following method: • Federal eRulemaking Portal: http:// www.regulations.gov. Follow the instructions for submitting comments. Instructions: All submissions received must include the agency name, docket number and title for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the Internet at http:// www.regulations.gov as they are received without change, including any personal identifiers or contact information. DoD Clearance Officer: Ms. Patricia Toppings Written requests for copies of the information collection proposal should be sent to Ms. Toppings at WHS/ESD/ Information Management Division, 1777 North Kent Street, RPN, Suite 11000, Arlington, VA 22209–2133. E:\FR\FM\01OCN1.SGM 01OCN1

Agencies

[Federal Register Volume 74, Number 189 (Thursday, October 1, 2009)]
[Notices]
[Pages 50785-50787]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-23738]


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

DEPARTMENT OF DEFENSE

Office of the Secretary


TRICARE; Civilian Health and Medical Program of the Uniformed 
Services (CHAMPUS); Fiscal Year 2010 Diagnosis Related Group (DRG) 
Updates

AGENCY: Office of the Secretary, DoD.

ACTION: Notice of DRG revised rates.

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

SUMMARY: This notice describes the changes made to the TRICARE DRG-
based payment system in order to

[[Page 50786]]

conform to changes made to the Medicare Prospective Payment System 
(PPS). It also provides the updated fixed loss cost outlier threshold, 
cost-to-charge ratios and the data necessary to update the Fiscal Year 
(FY) 2010 rates.

DATES: The rates, weights, and Medicare PPS changes which affect the 
TRICARE DRG-based payment system contained in this notice are effective 
for admissions occurring on or after October 1, 2009.

ADDRESSES: TRICARE Management Activity (TMA), Medical Benefits and 
Reimbursement Systems, 16401 East Centretech Parkway, Aurora, CO 80011-
9066.

FOR FURTHER INFORMATION CONTACT: Ann N. Fazzini, Medical Benefits and 
Reimbursement Branch, TMA, telephone (303) 676-3803.
    Questions regarding payment of specific claims under the TRICARE 
DRG-based payment system should be addressed to the appropriate 
contractor.

SUPPLEMENTARY INFORMATION: The final rule published on September 1, 
1987 (52 FR 32992) set forth the basic procedures used under the 
CHAMPUS DRG-based payment system. This was subsequently amended by 
final rules published August 31, 1988 (53 FR 33461), October 21, 1988 
(53 FR 41331), December 16, 1988 (53 FR 50515), May 30, 1990 (55 FR 
21863), October 22, 1990 (55 FR 42560), and September 10, 1998 (63 FR 
48439).
    An explicit tenet of these final rules, and one based on the 
statute authorizing the use of DRGs by TRICARE, is that the TRICARE 
DRG-based payment system is modeled on the Medicare PPS, and that, 
whenever practicable, the TRICARE system will follow the same rules 
that apply to the Medicare PPS. The Centers for Medicare and Medicaid 
Services (CMS) publishes these changes annually in the Federal Register 
and discusses in detail the impact of the changes.
    In addition, this notice updates the rates and weights in 
accordance with our previous final rules. The actual changes we are 
making, along with a description of their relationship to the Medicare 
PPS, are detailed below.

I. Medicare PPS Changes Which Affect the TRICARE DRG-Based Payment 
System

    Following is a discussion of the changes CMS has made to the 
Medicare PPS that affect the TRICARE DRG-based payment system.

A. DRG Classifications

    Under both the Medicare PPS and the TRICARE DRG-based payment 
system, cases are classified into the appropriate DRG by a Grouper 
program. The Grouper classifies each case into a DRG on the basis of 
the diagnosis and procedure codes and demographic information (that is, 
sex, age, and discharge status). The Grouper used for the TRICARE DRG-
based payment system is the same as the current Medicare Grouper with 
two modifications. The TRICARE system has replaced Medicare DRG 435 
with two age-based DRGs (900 and 901), and has implemented thirty-four 
(34) neonatal DRGs in place of Medicare DRGs 385 through 390. For 
admissions occurring on or after October 1, 2001, DRG 435 has been 
replaced by DRG 523. The TRICARE system has replaced DRG 523 with the 
two age-based DRGs (900 and 901). For admissions occurring on or after 
October 1, 1995, the CHAMPUS grouper hierarchy logic was changed so the 
age split (age <29 days) and assignments to Major Diagnostic Category 
(MDC) 15 occur before assignment of the PreMDC DRGs. This resulted in 
all neonate tracheostomies and organ transplants to be grouped to MDC 
15 and not to DRGs 480-483 or 495. For admissions occurring on or after 
October 1, 1998, the CHAMPUS grouper hierarchy logic was changed to 
move DRG 103 to the PreMDC DRGs and to assign patients to PreMDC DRGs 
480, 103 and 495 before assignment to MDC 15 DRGs and the neonatal 
DRGs. For admissions occurring on or after October 1, 2001, DRGs 512 
and 513 were added to the PreMDC DRGs, between DRGs 480 and 103 in the 
TRICARE grouper hierarchy logic. For admissions occurring on or after 
October 1, 2004, DRG 483 was deleted and replaced with DRGs 541 and 
542, splitting the assignment of cases on the basis of the performance 
of a major operating room procedure. The description for DRG 480 was 
changed to ``Liver Transplant and/or Intestinal Transplant,'' and the 
description for DRG 103 was changed to ``Heart/Heart Lung Transplant or 
Implant of Heart Assist System.'' For Fiscal Year 2007, CMS implemented 
classification changes, including surgical hierarchy changes. The 
TRICARE Grouper incorporated all changes made to the Medicare Grouper, 
with the exception of the pre-surgical hierarchy changes, which will 
remain the same as Fiscal Year 2006. For Fiscal Year 2008, Medicare 
implemented their Medicare-Severity DRG (MS-DRG) based payment system. 
TRICARE, however, continued with the Centers for Medicare and Medicaid 
Services DRG-based (CMS-DRG) payment system for Fiscal Year 2008. For 
Fiscal Year 2009, the TRICARE/CHAMPUS DRG-based payment system shall be 
modeled on the MS-DRG system, with the following modifications.
    The MS-DRG system consolidated the 43 pediatric CMS DRGs that were 
defined based on age less than or equal to 17 into the most clinically 
similar MS-DRGs. In their Inpatient Prospective Payment System final 
rule for MS-DRGs, Medicare stated for their population these pediatric 
CMS DRGs contained a very low volume of Medicare patients. At the same 
time, Medicare encouraged private insurers and other non-Medicare 
payers to make refinements to MS-DRGs to better suit the needs of the 
patients they serve. Consequently, TRICARE finds it appropriate to 
retain the pediatric CMS-DRGs for our population. TRICARE is also 
retaining the TRICARE-specific DRGs for neonates and substance use.
    TRICARE has retained the MS-DRG numbering system for Fiscal Year 
2009, and those TRICARE-specific DRGs have been assigned available, 
blank DRG numbers unused in the MS-DRG system. We refer the reader to 
http://www.tricare.mil/drgrates for a complete crosswalk containing the 
TRICARE DRG numbers for Fiscal Year 2009.
    For Fiscal Year 2009, TRICARE will use the MS-DRG v26.0 pre-MDC 
hierarchy, with the exception that MDC 15 is applied after DRG 011-012 
and before MDC 24.
    For Fiscal Year 2010, there are no additional or deleted DRGs.

B. Wage Index and Medicare Geographic Classification Review Board 
Guidelines

    TRICARE will continue to use the same wage index amounts used for 
the Medicare PPS. TRICARE will also duplicate all changes with regard 
to the wage index for specific hospitals that are redesignated by the 
Medicare Geographic Classification Review Board. In addition, TRICARE 
will continue to utilize the out commuting wage index adjustment.

C. Revision of the Labor-Related Share of the Wage Index

    TRICARE is adopting CMS' percentage of labor-related share of the 
standardized amount. For wage index values greater than 1.0, the labor-
related portion of the Adjusted Standardized Amount (ASA) shall equal 
68.8 percent. For wage-index values less than or equal to 1.0, the 
labor related portion of the ASA shall continue to equal 62 percent.

D. Hospital Market Basket

    TRICARE will update the adjusted standardized amounts according to 
the

[[Page 50787]]

final updated hospital market basket used for the Medicare PPS for all 
hospitals subject to the TRICARE DRG-based payment system according to 
CMS' August 27, 2009, final rule. For Fiscal Year 2010, the market 
basket is 2.1 percent.

E. Outlier Payments

    Since TRICARE does not include capital payments in our DRG-based 
payments (TRICARE reimburses hospitals for their capital costs as 
reported annually to the contractor on a pass-through basis), we will 
use the fixed-loss cost-outlier threshold calculated by CMS for paying 
cost outliers in the absence of capital prospective payments. For 
Fiscal Year 2010, the fixed-loss cost-outlier threshold is based on the 
sum of the applicable DRG-based payment rate plus any amounts payable 
for Indirect Medical Education (IDME) plus a fixed-dollar amount. Thus, 
for Fiscal Year 2010, in order for a case to qualify for cost outlier 
payments, the costs must exceed the TRICARE DRG base payment rate (wage 
adjusted) for the DRG plus the IDME payment plus $21,358 (wage 
adjusted). The marginal cost factor for cost outliers continues to be 
80 percent.

F. National Operating Standard Cost as a Share of Total Costs

    The Fiscal Year 2010 TRICARE National Operating Standard Cost as a 
Share of Total Costs (NOSCASTC) used in calculating the cost outlier 
threshold is 0.923. TRICARE uses the same methodology as CMS for 
calculating the NOSCASTC; however, the variables are different because 
TRICARE uses national cost to charge ratios while CMS uses hospital-
specific cost-to-charge ratios.

G. Indirect Medical Education (IDME) Adjustment

    Passage of the Medicare Prescription Drug Improvement and 
Modernization Act (MMA) of 2003 modified the formula multipliers to be 
used in the calculation of the indirect medical education IDME 
adjustment factor. Since the IDME formula used by TRICARE does not 
include disproportionate share hospitals (DSHs), the variables in the 
formula are different than Medicare's; however, the percentage 
reductions that will be applied to Medicare's formula will also be 
applied to the TRICARE IDME formula. The new multiplier for the IDME 
adjustment factor for TRICARE for Fiscal Year 2010 is 1.02.

H. Expansion of the Post-Acute-Care Transfer Policy

    For Fiscal Year 2010 TRICARE is adopting CMS' expanded post-acute-
care transfer policy according to CMS' final rule published August 27, 
2009.

I. Blood Clotting Factor

    For Fiscal Year 2010, TRICARE is adopting CMS' payment methodology 
for blood clotting factor according to CMS' final rule published August 
18, 2006.

J. Cost-to-Charge Ratio

    While CMS uses hospital-specific cost-to-charge ratios, TRICARE 
uses a national cost-to-charge ratio. For Fiscal Year 2010, the cost-
to-charge ratio used for the TRICARE DRG-based payment system for acute 
care hospitals and neonates will be 0.3740. This shall be used to 
calculate the adjusted standardized amounts and to calculate cost 
outlier payments, except for children's hospitals. For children's 
hospital cost outliers, the cost-to-charge ratio used is 0.4047.

K. Updated Rates and Weights

    The updated rates and weights are accessible through the Internet 
at http://www.tricare.osd.mil under the sequential headings TRICARE 
Provider Information, Rates and Reimbursements, and DRG Information. 
Table 1 provides the ASA rates and Table 2 provides the DRG weights to 
be used under the TRICARE DRG-based payment system during Fiscal Year 
2010. The implementing regulations for the TRICARE/CHAMPUS DRG-based 
payment system are in 32 CFR part 199.

    Dated: September 25, 2009.
Patricia L. Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. E9-23738 Filed 9-30-09; 8:45 am]
BILLING CODE 5001-06-P