TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year 2014 Diagnosis Related Group (DRG) Updates, 65618-65620 [2013-26108]
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65618
Federal Register / Vol. 78, No. 212 / Friday, November 1, 2013 / Notices
Committee for Purchase
From People Who Are Blind or Severely
Disabled, 1401 S. Clark Street, Suite
10800, Arlington, Virginia 22202–4149.
FOR FURTHER INFORMATION CONTACT:
Barry S. Lineback, Telephone: (703)
603–7740, Fax: (703) 603–0655, or email
CMTEFedReg@AbilityOne.gov.
SUPPLEMENTARY INFORMATION:
ADDRESSES:
NPA: Calcasieu Association for Retarded
Citizens, Inc., Lake Charles, LA
Contracting Activity: Dept of Commerce,
National Oceanic and Atmospheric
Administration, Boulder, CO
Contracting Activity: Dept of the Navy,
U.S. Fleet Forces Command, Norfolk, VA
Barry S. Lineback,
Director, Business Operations.
BILLING CODE 6353–01–P
Regulatory Flexibility Act Certification
I certify that the following action will
not have a significant impact on a
substantial number of small entities.
The major factors considered for this
certification were:
1. The action will not result in any
additional reporting, recordkeeping or
other compliance requirements for small
entities other than the small
organizations that will provide the
services to the Government.
2. The action will result in
authorizing small entities to provide the
services to the Government.
3. There are no known regulatory
alternatives which would accomplish
the objectives of the Javits-WagnerO’Day Act (41 U.S.C. 8501–8506) in
connection with the services proposed
for addition to the Procurement List.
DEPARTMENT OF DEFENSE
BILLING CODE 6353–01–P
Office of the Secretary
COMMITTEE FOR PURCHASE FROM
PEOPLE WHO ARE BLIND OR
SEVERELY DISABLED
Procurement List; Proposed Deletions
Committee for Purchase From
People Who Are Blind or Severely
Disabled.
AGENCY:
Proposed Deletions from the
Procurement List.
ACTION:
The Committee is proposing
to delete a product and service
previously furnished by nonprofit
agencies employing persons who are
blind or have other severe disabilities.
Comments Must Be Received on or
Before: 12/2/2013.
SUMMARY:
Committee for Purchase
From People Who Are Blind or Severely
Disabled, 1401 S. Clark Street, Suite
10800, Arlington, Virginia 22202–4149.
ADDRESSES:
FOR FURTHER INFORMATION OR TO SUBMIT
COMMENTS CONTACT: Barry S. Lineback,
Telephone: (703) 603–7740, Fax: (703)
603–0655, or email CMTEFedReg@
AbilityOne.gov.
This
notice is published pursuant to 41
U.S.C. 8503(a)(2) and 41 CFR 51–2.3. Its
purpose is to provide interested persons
an opportunity to submit comments on
the proposed actions.
SUPPLEMENTARY INFORMATION:
Deletions
Accordingly, the following services
are added to the Procurement List:
emcdonald on DSK67QTVN1PROD with NOTICES
End of Certification
The following product and service are
proposed for deletion from the
Procurement List:
Services
Service Type/Location: Custodial Service,
GSA, PBS, Region 2, Department of
State/Passport Office, Minillas North
Tower, 9th Floor, De Diego Ave. Parada
22, Santurce, PR
NPA: The Corporate Source, Inc., New York,
NY
Contracting Activity: GSA/Public Buildings
Service, HATO REY, PR
Service Type/Location: Janitorial/Custodial
Service, National Oceanic &
Atmospheric Administration, National
Weather Service Office, Except
Communication & Electrical Room, 500
Airport Blvd., #115, Lake Charles, LA.
VerDate Mar<15>2010
17:40 Oct 31, 2013
Jkt 232001
[FR Doc. 2013–26047 Filed 10–31–13; 8:45 am]
[FR Doc. 2013–26046 Filed 10–31–13; 8:45 am]
Additions
On 9/13/2013 (78 FR 56680) and
9/20/2013 (78 FR 57844), the Committee
for Purchase From People Who Are
Blind or Severely Disabled published
notices of proposed additions to the
Procurement List.
After consideration of the material
presented to it concerning capability of
qualified nonprofit agencies to provide
the services and impact of the additions
on the current or most recent
contractors, the Committee has
determined that the services listed
below are suitable for procurement by
the Federal Government under 41 U.S.C.
8501–8506 and 41 CFR 51–2.4.
Barry S. Lineback,
Director, Business Operations.
Product
NSN: 7930–01–367–0989—Cleaner, Water
Soluble
NPA: Association for the Blind and Visually
Impaired—Goodwill Industries of
Greater Rochester, Rochester, NY
Contracting Activity: General Services
Administration, Fort Worth, TX
Service
Service Type/Location: Janitorial/Custodial
Service, Naval & Marine Corps Reserve
Center, Spokane, WA
NPA: Career Connections, Spokane, WA
PO 00000
Frm 00014
Fmt 4703
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TRICARE; Civilian Health and Medical
Program of the Uniformed Services
(CHAMPUS); Fiscal Year 2014
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 DRGbased 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 FY 2014 rates.
DATES: Effective 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, 2013.
ADDRESSES: TRICARE Management
Activity (TMA), Medical Benefits and
Reimbursement Branch, 16401 East
Centretech Parkway, Aurora, CO 80011–
9066.
FOR FURTHER INFORMATION CONTACT:
Amber L. Butterfield, Medical Benefits
and Reimbursement Office, TMA,
telephone (303) 676–3565.
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
SUMMARY:
E:\FR\FM\01NON1.SGM
01NON1
Federal Register / Vol. 78, No. 212 / Friday, November 1, 2013 / Notices
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 in this
notice.
emcdonald on DSK67QTVN1PROD 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
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 pre-MDC 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 pre-MDC DRGs
and to assign patients to pre-MDC 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 pre-MDC 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,
VerDate Mar<15>2010
17:40 Oct 31, 2013
Jkt 232001
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 FY 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 FY 2006. For FY 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 FY 2008. For
FY 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.
For FY 09, 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 FY 10, there are no additional or
deleted DRGs.
For FY 11, the added DRGs and
deleted DRGs are the same as those
included in CMS’ final rule published
on August 16, 2010 (75 FR 50041–
50677). That is, DRG 009 is deleted;
DRGs 014 and 015 are being added.
For FY 12, the added DRGs and
deleted DRGs are the same as those
included in CMS’ Final rule published
on August 18, 2011 (76 FR 51475–
51846). That is, DRG 015 is deleted;
DRGs 016 and 017 are being added.
For FY 2013 there are no new,
revised, or deleted DRGs.
For FY 2014 there are no new,
revised, or deleted DRGs.
PO 00000
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Fmt 4703
Sfmt 4703
65619
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 69.6 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
final updated hospital market basket
used for the Medicare PPS for all
hospitals subject to the TRICARE DRGbased payment system according to
CMS’ August 19, 2013 final rule (78 FR
50495–51040). For FY 2014, the market
basket is 2.5 percent. Medicare applied
reductions to the market basket in FY
2014; however, these reductions do not
apply to the TRICARE Program.
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 FY 2014, 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 FY 2014, 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 $20,008 (wage adjusted).
The marginal cost factor for cost outliers
continues to be 80 percent.
An incorrect FY 2013 TRICARE Cost
Outlier Threshold of $24,230 was
published in the Federal Register notice
(77 FR 71180–71182). However, the
correct FY 2013 TRICARE Cost Outlier
E:\FR\FM\01NON1.SGM
01NON1
65620
Federal Register / Vol. 78, No. 212 / Friday, November 1, 2013 / Notices
Threshold of $20,075 was published in
the TRICARE Reimbursement Manual
(TRM) and was effective as of October
1, 2012.
Dated: October 29, 2013.
Aaron Siegel,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
F. National Operating Standard Cost as
a Share of Total Costs
[FR Doc. 2013–26108 Filed 10–31–13; 8:45 am]
The FY 2013 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
emcdonald on DSK67QTVN1PROD with NOTICES
H. Cost to Charge Ratio
TRICARE uses a national Medicare
cost-to-charge ratio (CCR). For FY 2014,
the Medicare CCR used for the TRICARE
DRG-based payment system for acute
care hospitals and neonates will be
0.2778. This is based on a weighted
average of the hospital-specific
Medicare CCRs (weighted by the
number of Medicare discharges) after
excluding hospitals not subject to the
TRICARE DRG system (Sole Community
Hospitals, Indian Health Service
hospitals, and hospitals in Maryland).
The Medicare CCR is used to calculate
cost outlier payments, except for
children’s hospitals. The Medicare CCR
has been increased by a factor of 1.0065
to include an additional allowance for
bad debt. The 1.0065 factor reflects the
provisions of the Middle Class Tax
Relief and Job Creation Act of 2012. For
children’s hospital cost outliers, the
CCR used is 0.3012.
I. Updated Rates and Weights
The updated rates and weights are
accessible through the Internet at
https://www.tricare.mil/drgrates. The
implementing regulations for the
TRICARE/CHAMPUS DRG-based
payment system are in 32 CFR Part 199.
17:40 Oct 31, 2013
Jkt 232001
DEPARTMENT OF DEFENSE
Department of the Navy
[Docket ID: USN–2013–0007]
Privacy Act of 1974; System of
Records
Department of the Navy, DoD.
Notice to alter a System of
Records.
AGENCY:
ACTION:
The Department of the Navy
proposes to alter a system of records in
its inventory of record systems subject
to the Privacy Act of 1974, as amended.
This notice proposes to alter N01080–2,
Officer Master File Automated Systems.
DATES: This proposed action will be
effective on December 2, 2013 unless
comments are received which result in
a contrary determination. Comments
will be accepted on or before December
2, 2013.
ADDRESSES: You may submit comments,
identified by docket number and title,
by any of the following methods:
* Federal Rulemaking Portal: https://
www.regulations.gov. Follow the
instructions for submitting comments.
* Mail: Federal Docket Management
System Office, 4800 Mark Center Drive,
East Tower, 2nd Floor, Suite 02G09,
Alexandria, VA 22350–3100.
Instructions: All submissions received
must include the agency name and
docket number 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.
SUMMARY:
Passage of the Medical Modernization
Act of 2003 modified the formula
multipliers to be used in the calculation
of 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 multiplier for the
IDME adjustment factor for TRICARE for
FY 2014 is 1.02.
VerDate Mar<15>2010
BILLING CODE 5001–06–P
Ms.
Robin Patterson, Head, PA/FOIA Office
(DNS–36), Department of the Navy,
2000 Navy Pentagon, Washington, DC
20350–2000, or by phone at (202) 685–
6545.
SUPPLEMENTARY INFORMATION: The
Department of the Navy’s notices for
systems of records subject to the Privacy
Act of 1974 (5 U.S.C. 552a), as amended,
have been published in the Federal
Register and are available from the
address in FOR FURTHER INFORMATION
CONTACT. The proposed system report,
FOR FURTHER INFORMATION CONTACT:
PO 00000
Frm 00016
Fmt 4703
Sfmt 4703
as required by 5 U.S.C. 552a(r) of the
Privacy Act of 1974, as amended, was
submitted on March 18, 2013, to the
House Committee on Oversight and
Government Reform, the Senate
Committee on Governmental Affairs,
and the Office of Management and
Budget (OMB) pursuant to paragraph 4c
of Appendix I to OMB Circular No. A–
130, ‘‘Federal Agency Responsibilities
for Maintaining Records About
Individuals,’’ dated February 8, 1996
(February 20, 1996, 61 FR 6427).
Dated: October 29, 2013.
Aaron Siegel,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
N01080–2
SYSTEM NAME:
Officer Master File Automated
Systems (September 21, 2006, 71 FR
55172).
CHANGES:
*
*
*
*
*
SYSTEM LOCATION:
Delete entry and replace with
‘‘Defense Information Systems Agency
(DISA), 5450 Carlisle Pike,
Mechanicsburg, PA 17050–0975.’’
*
*
*
*
*
CATEGORIES OF RECORDS IN THE SYSTEM:
Delete entry and replace with
‘‘System contains personnel data to
support officer assignment, planning,
programming, accounting, promotions,
career development, and procurement,
including: Name, Social Security
Number (SSN), rank, status, education,
training, security clearance,
qualifications, assignments,
performance, service, rotation and
retirement dates, marital status, and
number of dependants. The system also
contains Activity Personnel Diaries,
personnel accounting documents,
Reserve Unit Drill reports, and other
personnel transaction documents
necessary to maintain file accuracy and
currency.’’
*
*
*
*
*
STORAGE:
Delete entry and replace with ‘‘Paper
and electronic storage media.’’
*
*
*
*
*
RETENTION AND DISPOSAL:
Delete entry and replace with
‘‘Records are maintained in accordance
with the Department of the Navy
Records Management Program, Records
Management Manual, SECNAV M–
5210.1, January 2012, SSIC 1080, due to
the large volume they are available at
E:\FR\FM\01NON1.SGM
01NON1
]]>Agencies
[Federal Register Volume 78, Number 212 (Friday, November 1, 2013)]
[Notices]
[Pages 65618-65620]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-26108]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE; Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS); Fiscal Year 2014 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 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 FY 2014 rates.
DATES: Effective 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,
2013.
ADDRESSES: TRICARE Management Activity (TMA), Medical Benefits and
Reimbursement Branch, 16401 East Centretech Parkway, Aurora, CO 80011-
9066.
FOR FURTHER INFORMATION CONTACT: Amber L. Butterfield, Medical Benefits
and Reimbursement Office, TMA, telephone (303) 676-3565.
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
[[Page 65619]]
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 in this notice.
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 pre-MDC 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 pre-MDC DRGs and to assign patients to pre-MDC 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 pre-MDC 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 FY 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 FY 2006. For FY 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 FY 2008. For FY 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.
For FY 09, 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 FY 10, there are no additional or deleted DRGs.
For FY 11, the added DRGs and deleted DRGs are the same as those
included in CMS' final rule published on August 16, 2010 (75 FR 50041-
50677). That is, DRG 009 is deleted; DRGs 014 and 015 are being added.
For FY 12, the added DRGs and deleted DRGs are the same as those
included in CMS' Final rule published on August 18, 2011 (76 FR 51475-
51846). That is, DRG 015 is deleted; DRGs 016 and 017 are being added.
For FY 2013 there are no new, revised, or deleted DRGs.
For FY 2014 there are no new, revised, 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
69.6 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 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 19, 2013 final rule (78 FR 50495-51040). For FY 2014,
the market basket is 2.5 percent. Medicare applied reductions to the
market basket in FY 2014; however, these reductions do not apply to the
TRICARE Program.
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 FY
2014, 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
FY 2014, 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 $20,008 (wage adjusted). The
marginal cost factor for cost outliers continues to be 80 percent.
An incorrect FY 2013 TRICARE Cost Outlier Threshold of $24,230 was
published in the Federal Register notice (77 FR 71180-71182). However,
the correct FY 2013 TRICARE Cost Outlier
[[Page 65620]]
Threshold of $20,075 was published in the TRICARE Reimbursement Manual
(TRM) and was effective as of October 1, 2012.
F. National Operating Standard Cost as a Share of Total Costs
The FY 2013 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 Medical Modernization Act of 2003 modified the
formula multipliers to be used in the calculation of 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 multiplier for the IDME adjustment factor for
TRICARE for FY 2014 is 1.02.
H. Cost to Charge Ratio
TRICARE uses a national Medicare cost-to-charge ratio (CCR). For FY
2014, the Medicare CCR used for the TRICARE DRG-based payment system
for acute care hospitals and neonates will be 0.2778. This is based on
a weighted average of the hospital-specific Medicare CCRs (weighted by
the number of Medicare discharges) after excluding hospitals not
subject to the TRICARE DRG system (Sole Community Hospitals, Indian
Health Service hospitals, and hospitals in Maryland). The Medicare CCR
is used to calculate cost outlier payments, except for children's
hospitals. The Medicare CCR has been increased by a factor of 1.0065 to
include an additional allowance for bad debt. The 1.0065 factor
reflects the provisions of the Middle Class Tax Relief and Job Creation
Act of 2012. For children's hospital cost outliers, the CCR used is
0.3012.
I. Updated Rates and Weights
The updated rates and weights are accessible through the Internet
at https://www.tricare.mil/drgrates. The implementing regulations for
the TRICARE/CHAMPUS DRG-based payment system are in 32 CFR Part 199.
Dated: October 29, 2013.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2013-26108 Filed 10-31-13; 8:45 am]
BILLING CODE 5001-06-P
