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