TRICARE; Formerly Known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year 2011 Diagnosis-Related Group (DRG) Updates, 79348-79350 [2010-31792]
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79348
Federal Register / Vol. 75, No. 243 / Monday, December 20, 2010 / Notices
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:
In addition to those disclosures
generally permitted under 5 U.S.C.
552a(b) of the Privacy Act, as amended,
these records may specifically be
disclosed outside the Department of
Defense as a routine use pursuant to 5
U.S.C. 552a(b)(3) as follows:
To interface with all commercial
insurance carriers and parties against
whom recovery has been sought by the
Department of Defense Military Health
System, as well as all parties involved
in support of the collection activities for
health care approved by the Department
of Defense.
To the National Data Clearinghouse,
an electronic healthcare clearinghouse,
for purposes of converting the data to an
industry-wide format prior to
forwarding the billing information to the
insurance companies for payment.
The DoD ‘Blanket Routine Uses’ set
forth at the beginning of Office of the
Secretary of Defense’s compilation of
systems of records notices apply to this
system.
Note 1: This system of records contains
individually identifiable health information.
The Department of Defense Health
Information Privacy Regulation (DoD
6025.18–R) issued pursuant to the Health
Insurance Portability and Accountability Act
of 1996, applies to most such health
information. DoD 6025.18–R may place
additional procedural requirements on the
uses and disclosures of such information
beyond what is found in the Privacy Act of
1974 or mentioned in this system of records
notice.
Note 2: Personal identity, diagnosis,
prognosis or treatment information of any
patient maintained in connection with the
performance of any program or activity
relating to substance abuse education,
prevention, training, treatment,
rehabilitation, or research, which is
conducted, regulated, or directly or indirectly
assisted by any department or agency of the
United States is, except as per 42 U.S.C.
290dd–2, treated as confidential and
disclosed only for the purposes and under
the circumstances expressly authorized
under 42 U.S.C. 290dd–2.
POLICIES AND PRACTICES FOR STORING,
RETRIEVING, ACCESSING, RETAINING, AND
DISPOSING OF RECORDS IN THE SYSTEM:
jlentini on DSKJ8SOYB1PROD with NOTICES
STORAGE:
Paper file folders and electronic
storage media.
RETRIEVABILITY:
Records are retrieved by the sponsor
or patient name, Social Security
Number, Department of Defense
Benefits Number, third party payer
identification number assigned to
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Jkt 223001
individual, family member prefix (a
two-digit code identifying the person’s
relationship to the Military Sponsor),
and/or Patient Control Number.
SAFEGUARDS:
Physical access to system location
restricted by cipher locks, visitor escort,
access rosters, and photo identification.
Adequate locks on doors and server
components secured in a locked
computer room with limited access.
Each system end user device protected
within a locked storage container, room,
or building outside of normal business
hours. All visitors and other persons
that require access to facilities that
house servers and other network devices
supporting the system that do not have
authorization for access escorted by
appropriately screened/cleared
personnel at all times.
Access to the system is role-based and
a valid user account is required. The
system provides two-factor
authentication, using either a Common
Access Card and Personal Identification
Number or a unique logon identification
and password. Where a unique logon
identification and password is used,
passwords must be renewed every sixty
(60) days. Authorized personnel must
have appropriate Information Assurance
training, Health Insurance Portability
and Accountability Act training, and
Privacy Act of 1974 training.
RETENTION AND DISPOSAL:
Records are destroyed five years after
the end of the year in which the record
was closed.
SYSTEM MANAGER(S) AND ADDRESS:
Program Manager, Defense Health
Services Systems, Suite 1500, 5203
Leesburg Pike, Falls Church, VA 22041–
3891.
NOTIFICATION PROCEDURE:
Individuals seeking to determine
whether this system contains
information about themselves should
address written inquires to the
TRICARE Management Activity,
Department of Defense, ATTN: TMA
Privacy Officer, Suite 810, 5111
Leesburg Pike, Falls Church, VA 22041–
3206.
Request should contain participant’s
and/or sponsor’s full name, their Social
Security Number (SSN), and current
address and telephone number and the
names of the military treatment facility
or facilities in which they have received
medical treatment.
If requesting health information of a
minor (or legally incompetent person),
the request must be made by a custodial
parent, legal guardian, or party acting in
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loco parentis of such individual(s).
Written proof of the capacity of the
requestor may be required.
RECORD ACCESS PROCEDURES:
Individuals seeking access to records
about themselves contained in this
system should address written inquiries
to TRICARE Management Activity,
Attention: Freedom of Information Act
Requester Service Center, 16401 East
Centretech Parkway, Aurora, CO 80011–
9066.
Requests should contain participant’s
and/or sponsor’s full name, their Social
Security Number (SSN), and current
address and telephone number and the
names of the military treatment facility
or facilities in which they have received
medical treatment.
If requesting health information of a
minor (or legally incompetent person),
the request must be made by a custodial
parent, legal guardian, or party acting in
loco parentis of such individual(s).
Written proof of the capacity of the
requestor may be required.
CONTESTING RECORD PROCEDURES:
The Office of the Secretary of Defense
rules for accessing records, for
contesting contents and appealing
initial agency determinations are
published in Office of the Secretary of
Defense Administrative Instruction 81
(32 CFR part 311) or may be obtained
from the system manager.
RECORD SOURCE CATEGORIES:
Information is obtained from an
automated medical records system, the
Composite Health Care System
(specifically, the Ambulatory Data
Module), which is automatically sent to
the Third Party Collection System.
Other information may be obtained from
the AHLTA System and the Theater
Data Medical Stores System.
EXEMPTIONS CLAIMED FOR THE SYSTEM:
None.
[FR Doc. 2010–31789 Filed 12–17–10; 8:45 am]
BILLING CODE 5001–06–P
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE; Formerly Known as the
Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS);
Fiscal Year 2011 Diagnosis-Related
Group (DRG) Updates
Office of the Secretary, DoD.
Notice of DRG revised rates.
AGENCY:
ACTION:
This notice describes the
changes made to the TRICARE DRG-
SUMMARY:
E:\FR\FM\20DEN1.SGM
20DEN1
Federal Register / Vol. 75, No. 243 / Monday, December 20, 2010 / Notices
based payment system in order to
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 2011 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, 2010.
ADDRESSES: TRICARE Management
Activity (TMA), Medical Benefits and
Reimbursement Branch, 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.
jlentini on DSKJ8SOYB1PROD 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,
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17:18 Dec 17, 2010
Jkt 223001
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 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
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Fmt 4703
Sfmt 4703
79349
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.
For Fiscal Year 2011, the added DRGs
and deleted DRGs are the same as those
included in CMS’ final rule published
on August 16, 2010. That is, DRG 009
is deleted; DRGs 014 and 015 are being
added.
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.
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79350
Federal Register / Vol. 75, No. 243 / Monday, December 20, 2010 / Notices
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
final updated hospital market basket
used for the Medicare PPS for all
hospitals subject to the TRICARE DRGbased payment system according to
CMS’s August 16, 2010, final rule. For
Fiscal Year 2011, the market basket is
2.6 percent. This year, Medicare applied
two reductions to their market basket
amount: (1) A 0.25 percent reduction
due to provisions found in the Patient
Protection and Affordable Care Act, and
(2) a 2.9 percent reduction for
documentation and coding adjustments
found in Public Law 110–90. These two
reductions do not apply to TRICARE.
jlentini on DSKJ8SOYB1PROD with NOTICES
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
2011, the TRICARE 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
2011, in order for a case to qualify for
cost outlier payments, the costs must
exceed the TRICARE DRG-based
payment rate (wage adjusted) for the
DRG plus the IDME payment plus
$21,229 (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 2011 TRICARE
National Operating Standard Cost as a
Share of Total Costs (NOSCASTC) used
in calculating the cost outlier threshold
is 0.92. 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
Modernization Act of 2003 modified the
formula multipliers to be used in the
calculation of the indirect medical
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17:18 Dec 17, 2010
Jkt 223001
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 2011 is 1.02.
H. Expansion of the Post Acute Care
Transfer Policy
For Fiscal Year 2011 TRICARE is
adopting CMS’ expanded post acute
care transfer policy according to CMS’
final rule published August 16, 2010.
I. Cost-to-Charge Ratio
While CMS uses hospital-specific
cost-to-charge ratios, TRICARE uses a
national cost-to-charge ratio. For Fiscal
Year 2011, the cost-to-charge ratio used
for the TRICARE DRG-based payment
system for acute care hospitals and
neonates will be 0.3664. 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 0.3974.
J. 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 2011. The
implementing regulations for the
TRICARE/CHAMPUS DRG-based
payment system are in 32 CFR Part 199.
Dated: December 14, 2010.
Morgan F. Park,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
[FR Doc. 2010–31792 Filed 12–17–10; 8:45 am]
BILLING CODE 5001–06–P
DEPARTMENT OF EDUCATION
Notice of Submission for OMB Review
Department of Education.
Comment request.
AGENCY:
ACTION:
The Director, Information
Collection Clearance Division,
Regulatory Information Management
Services, Office of Management invites
comments on the submission for OMB
SUMMARY:
PO 00000
Frm 00017
Fmt 4703
Sfmt 4703
review as required by the Paperwork
Reduction Act of 1995 (Pub. L. 104–13).
DATES: Interested persons are invited to
submit comments on or before January
19, 2011.
ADDRESSES: Written comments should
be addressed to the Office of
Information and Regulatory Affairs,
Attention: Education Desk Officer,
Office of Management and Budget, 725
17th Street, NW., Room 10222, New
Executive Office Building, Washington,
DC 20503, be faxed to (202) 395–5806 or
e-mailed to oira_submission@omb.eop.
gov with a cc: to ICDocketMgr@ed.gov.
Please note that written comments
received in response to this notice will
be considered public records.
SUPPLEMENTARY INFORMATION: Section
3506 of the Paperwork Reduction Act of
1995 (44 U.S.C. Chapter 35) requires
that the Office of Management and
Budget (OMB) provide interested
Federal agencies and the public an early
opportunity to comment on information
collection requests. The OMB is
particularly interested in comments
which: (1) Evaluate whether the
proposed collection of information is
necessary for the proper performance of
the functions of the agency, including
whether the information will have
practical utility; (2) Evaluate the
accuracy of the agency’s estimate of the
burden of the proposed collection of
information, including the validity of
the methodology and assumptions used;
(3) Enhance the quality, utility, and
clarity of the information to be
collected; and (4) Minimize the burden
of the collection of information on those
who are to respond, including through
the use of appropriate automated,
electronic, mechanical, or other
technological collection techniques or
other forms of information technology.
Dated: December 14, 2010.
Darrin A. King,
Director, Information Collection Clearance
Division, Regulatory Information
Management Services, Office of Management.
Institute of Education Sciences
Type of Review: Revision.
Title of Collection: High School
Longitudinal Study of 2009 (HSLS:09)
First Follow-up Field Test 2011.
OMB Control Number: 1850–0852.
Agency Form Number(s): N/A.
Frequency of Responses: Annually.
Affected Public: Individuals or
household.
Total Estimated Number of Annual
Responses: 6,873.
Total Estimated Annual Burden
Hours: 1,161.
Abstract: The High School
Longitudinal Study of 2009 (HSLS:09) is
E:\FR\FM\20DEN1.SGM
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]]>Agencies
[Federal Register Volume 75, Number 243 (Monday, December 20, 2010)]
[Notices]
[Pages 79348-79350]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-31792]
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE; Formerly Known as the Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS); Fiscal Year 2011
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-
[[Page 79349]]
based payment system in order to 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 2011 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, 2010.
ADDRESSES: TRICARE Management Activity (TMA), Medical Benefits and
Reimbursement Branch, 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.
For Fiscal Year 2011, the added DRGs and deleted DRGs are the same
as those included in CMS' final rule published on August 16, 2010. That
is, DRG 009 is deleted; DRGs 014 and 015 are being added.
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.
[[Page 79350]]
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 final updated hospital market basket used for the Medicare PPS for
all hospitals subject to the TRICARE DRG-based payment system according
to CMS's August 16, 2010, final rule. For Fiscal Year 2011, the market
basket is 2.6 percent. This year, Medicare applied two reductions to
their market basket amount: (1) A 0.25 percent reduction due to
provisions found in the Patient Protection and Affordable Care Act, and
(2) a 2.9 percent reduction for documentation and coding adjustments
found in Public Law 110-90. These two reductions do not apply to
TRICARE.
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 2011, the TRICARE 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 2011, in order for a case to
qualify for cost outlier payments, the costs must exceed the TRICARE
DRG-based payment rate (wage adjusted) for the DRG plus the IDME
payment plus $21,229 (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 2011 TRICARE National Operating Standard Cost as a
Share of Total Costs (NOSCASTC) used in calculating the cost outlier
threshold is 0.92. 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 Modernization Act 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 2011 is
1.02.
H. Expansion of the Post Acute Care Transfer Policy
For Fiscal Year 2011 TRICARE is adopting CMS' expanded post acute
care transfer policy according to CMS' final rule published August 16,
2010.
I. Cost-to-Charge Ratio
While CMS uses hospital-specific cost-to-charge ratios, TRICARE
uses a national cost-to-charge ratio. For Fiscal Year 2011, the cost-
to-charge ratio used for the TRICARE DRG-based payment system for acute
care hospitals and neonates will be 0.3664. 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 0.3974.
J. 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
2011. The implementing regulations for the TRICARE/CHAMPUS DRG-based
payment system are in 32 CFR Part 199.
Dated: December 14, 2010.
Morgan F. Park,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2010-31792 Filed 12-17-10; 8:45 am]
BILLING CODE 5001-06-P
