3.1 Areas Affected
3.1.1 The TRICARE DRG-based payment system shall
apply to hospital services in the 50 United States (U.S.), the District
of Columbia, and Puerto Rico. The DRG-based payment system shall
not be used with regard to services rendered outside the 50 U.S.,
the District of Columbia, or Puerto Rico.
3.1.2 State waivers. Any state which has implemented
a separate DRG-based payment system or similar payment system in
order to control costs may be exempt from the TRICARE DRG-based
payment system under the following circumstances:
• The following requirements
must be met in order for a state to be exempt.
• The state must be
exempt from the Medicare Inpatient Prospective
Payment System (IPPS);
• The state must request,
in writing to DHA, that it be exempt from the TRICARE DRG-based
payment system; and
• Payments in the state
must continue to be at a level to maintain savings comparable to those
which would be achieved under the TRICARE DRG-based payment system.
DHA will monitor reimbursement levels in any exempted state to ensure
that payment levels there do not exceed those under the TRICARE
DRG-based payment system. If they do exceed that level, DHA will
work with the state to resolve the problem. However, if a satisfactory
solution cannot be found, DHA will terminate the exemption after
due notice has been given to the state.
3.3 Services
Exempt From The DRG-Based Payment System
The
following hospital services, even when provided in a hospital subject
to the TRICARE DRG-based payment system, are exempt from the TRICARE
DRG-based payment system and shall be reimbursed under the appropriate
procedures.
3.3.1 Services provided by hospitals exempt from
the DRG-based payment system as defined in
paragraph 3.6.
3.3.2 All services
related to TRICARE covered solid organ transplants for which there
is no DRG assignment.
3.3.3 All services related to solid
organ acquisition, including the costs of the donor’s inpatient stay
for TRICARE covered transplants by TRICARE authorized transplantation
centers. Acquisition costs related to solid organ transplants shall
be paid on a reasonable cost basis and are not included in the DRG.
3.3.4 All services
provided by hospital-based professionals (physicians, psychologists,
etc.) which, under normal TRICARE requirements, would be billed
by the hospital. This does not include any therapy services (physical,
speech, etc.), since these are included in the DRG-based payment.
For radiology and pathology services provided by hospital-based
physicians, any related non-professional (i.e., technical) component
of these services is included in the DRG-based payment and cannot
be billed separately. The services of hospital-based professionals
which are employed by, or under contract to, a hospital must still
be billed by the hospital and must be billed on a participating
basis.
3.3.5 Anesthesia services provided by nurse anesthetists.
This may be separately billed only when the nurse anesthetist is
the primary anesthetist for the case.
Note: As a general
rule, TRICARE will only pay for one anesthesia claim per case. When
an anesthesiologist is paid for anesthesia services, a nurse anesthetist
is not authorized to bill for those same services. Services which
support the anesthesiologist in the operating room fall within the
DRG allowed amount and are considered to be already included in
the facility fee, even if the support services are provided by a
nurse anesthetist. Charging for such services is considered an inappropriate billing
practice.
3.3.6 All outpatient services related
to inpatient stays.
Note: Payment for trauma
services (e.g., revenue code 068X), is included in the TRICARE DRG-based
payment system.
3.3.7 All services related to discharges
involving pediatric (beneficiary less than 18 years old upon admission)
bone marrow transplants which would otherwise be paid under the
DRGs for such transplants.
3.3.8 All services related to discharges
involving children (beneficiary less than 18 years old upon admission)
who have been determined to be Human
Immunodeficiency Virus (HIV) seropositive.
3.3.9 All services
related to discharges involving pediatric (beneficiary less than
18 years old upon admission) cystic fibrosis.
3.3.10 For services
provided before the mandated date, as directed by Health and Human
Services (HHS), for International Classification of Diseases, 10th
Revision (ICD-10) implementation, an additional payment shall be
made to a hospital for each unit of blood clotting factor furnished
to a TRICARE patient who is a hemophiliac. Payment will be made
for blood clotting factor when one of the following hemophilia International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) diagnosis codes is listed on the claim:
|
|
286.0
|
Congenital Factor
VIII Disorder
|
|
|
286.1
|
Congenital Factor
IX Disorder
|
|
|
286.2
|
Congenital Factor
XI Deficiency
|
|
|
286.3
|
Congenital Deficiency
of Other Clotting Factors
|
|
|
286.4
|
Von Willebrand’s
Disease
|
|
|
286.5
|
Hemorrhagic Disorder
Due to Circulating Anticoagulants
|
|
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286.7
|
Acquired Coagulation
Factor Deficiency
|
3.3.11 For services
provided on or after the mandated date, as directed by HHS, for
ICD-10 implementation, an additional payment shall be made to a
hospital for each unit of blood clotting factor furnished to a TRICARE
patient who is a hemophiliac. Payment will be made for blood clotting factor
when one of the following hemophilia ICD-10-CM diagnosis codes is
listed on the claim:
|
|
D66
|
Hereditary Factor
VIII Deficiency
|
|
|
D67
|
Hereditary Factor
IX Deficiency
|
|
|
D68.0
|
Von Willebrand’s
Disease
|
|
|
D68.1
|
Hereditary Factor
XI Deficiency
|
|
|
D68.2
|
Hereditary Deficiency
of Other Clotting Factors
|
|
|
D68.31
|
Hemorrhagic Disorder
Due to Intrinsic Circulating Anticoagulants
|
|
|
D68.4
|
Acquired Coagulation Factor
Deficiency
|
Note: Since the costs of blood clotting factor are reimbursed
separately, for these claims all charges associated with the factor
are to be subtracted from the total charges in determining applicability
of a cost outlier. However, the charges for the blood clotting factor
are to be included when calculating the cost-share based on billed
charges.
3.3.12 Contractors
shall make payment for blood clotting factor using Average Sale
Price (ASP) plus 6%, using the Medicare Part B Drug Pricing file.
The price allows for payment of a furnishing fee and is included
in the ASP per unit.
3.6 The
following types of hospitals or units which are exempt from the
Medicare
IPPS, are exempt from the
TRICARE DRG-based payment system. In order for hospitals and units
which do not participate in Medicare to be exempt from the TRICARE
DRG-based payment system, they must meet the same criteria (as determined
by DHA, or designee) as required for exemption from the Medicare
IPPS as contained
in Section 412 of Title 42 CFR.
3.6.1 Hospitals within hospitals.
3.6.2 Psychiatric
hospitals.
3.6.3 Rehabilitation hospitals.
3.6.4 Psychiatric
and rehabilitation units (distinct parts).
3.6.5 Long-term hospitals.
3.6.6 Sole Community
Hospitals (SCHs).
3.6.7 Christian Science sanitariums.
3.6.8 Cancer
hospitals. Any hospital which qualifies as a cancer hospital under
the Medicare standards and has elected to be exempt from the Medicare IPPS is
exempt from the TRICARE DRG-based payment system.
3.6.9 Hospitals
outside the 50 U.S., the District of Columbia, and Puerto Rico.
3.6.10 Satellite
facilities.