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
|
|
|
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.