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.