1.0 APPLICABILITY
This policy is mandatory for
reimbursement of all hospital inpatient services provided in the
locations identified in
paragraph 4.2. This policy revises, replaces,
and supersedes the previously issued policy, effective October 1,
2004, for hospital reimbursement in the Philippines. Puerto Rico
follows Continental United States (CONUS) based reimbursement methodologies
used for the 50 U.S. and the District of Columbia.
3.0 POLICY
The institutional per diem
for those specified locations outside the 50 U.S. and the District
of Columbia is the maximum amount TRICARE will authorize to be paid
for inpatient services on a per diem basis. The allowable institutional
rates for those specified locations outside the 50 U.S. and the
District of Columbia, shall be the lesser of (a) billed charges
or; (b) the amount based upon prospectively determined per diems
which are adjusted by a country specific index factor.
4.0 BACKGROUND
Reimbursement Systems:
4.1 General
4.1.1 Payment for inpatient hospital
stays in specified locations outside the 50 U.S. and the District
of Columbia, are made utilizing the lesser of:
• Billed charges; or
• The prospectively determined
per diems adjusted by a country specific index.
4.1.2 The prospectively determined
per diem rates for specified locations outside the 50 U.S. and the
District of Columbia, are developed into reimbursement groupings
by utilizing diagnosis codes. 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,
use diagnosis codes as contained in the International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). For
services provided on or after the mandated date, as directed by
HHS, for ICD-10 implementation, use diagnosis codes as contained
in the ICD-10-CM. The per diem rates are the maximum allowable amounts
that the TRICARE Program will reimburse and the amount on which
patient cost-shares are calculated. The National U.S. per diem rate
is multiplied by a unique country specific index factor which adjusts
the National U.S. per diems for the applicable country. The country
specific hospital per diem, for those specified locations outside
the 50 U.S. and the District of Columbia is the product of the National
U.S. per diem and the country specific index.
4.2
Applicability
4.2.1 This payment system applies
to all hospitals providing services in:
• The Philippines.
• Panama.
• Other as designated by the
Government.
4.2.2 This payment system will be
applied by the foreign claims processor. It applies to hospital inpatient
services furnished to TRICARE beneficiaries, other than TRICARE
Prime Active Duty Family Members (ADFMs) falling under the claims
processing jurisdiction of the foreign claims processor.
4.2.3 Institutional providers accepting,
admitting and treating TRICARE beneficiaries will receive the per
diem reimbursement on applicable hospital services included on inpatient
claims. This payment system shall be used regardless of the type
of hospital inpatient services provided. The prospectively determined
per diem rates established under this system are all-inclusive and
are intended to include, but not be limited to, a standard amount
for nursing and technician services; room, board and meals; drugs
including any take home drugs; biologicals; surgical dressings,
splints, casts; Durable Medical Equipment (DME) for use in the hospital
and is related to the provision of a surgical service, procedure
or procedures, equipment related to the provision and performance
of surgical procedures; laboratory services and testing; X-ray or
other diagnostic procedures directly related to the inpatient Episode
Of Care (EOC); special unit operating costs, such as intensive care
units; malpractice costs, if applicable, or other administrative
costs related to the services furnished to the patients, recordkeeping
and the provision of records; housekeeping items and services; and
capital costs.
4.2.4 The per
diem rates do not include such items as physicians’ fees, irrespective
of a physician’s employment status with the hospital. The per diem
rates do not include other professional providers (e.g., nurse anesthetist)
recognized by TRICARE who render directly related inpatient services and
bill independently from the hospital for them. A valid primary ICD-9-CM
code or narrative description of services must be submitted by the
hospital or institutional provider for services provided before
the mandated date, as directed by HHS, for ICD-10 implementation.
A valid primary ICD-10-CM code or narrative description of services
must be submitted by the hospital or institutional provider for services
provided on or after the mandated date, as directed by HHS, for
ICD-10 implementation. The medical description provided shall be
able to support development of the claim by the overseas claims processor
prior to reimbursement.
4.3 Country Specific Index
The country specific index
is a factor obtained from the World Bank’s International Comparison Program.
The index factor, known as Purchasing Power Parity (PPP) conversion
factor, is based upon a large array of goods and services or market
basket within the specific country which is then standardized and
weighted to a U.S. standard and currency. The World Bank defines
PPP conversion factor as: “Number of units of a country’s currency
required to buy the same amount of goods and services in the domestic
market that a U.S. dollar would buy in the U.S.” The use of the
country specific index enables a conversion and therefore creates
parity between the U.S. and the specific country in the purchasing
of the same amount and type of medical services. TRICARE is utilizing
the World Bank’s International Comparison Program country specific
index as provided in
Figure 1.34-1.
4.4 Institutional Payment Rates
4.4.3 The rate setting methodology
was developed as follows:
4.4.3.1 For services provided before
the mandated date, as directed by HHS, for ICD-10 implementation:
• A rate setting methodology
utilizing the first three digits of a primary diagnosis code.
• Eighteen diagnosis groupings
were defined and designed based upon the groupings and definitions
contained in the ICD-9-CM publication. For example, Group 1 is defined
as ICD-9-CM codes 001 to 139, or Infectious and Parasitic Diseases.
The first three digits of a primary diagnosis code are utilized
for placement into one of the 18 groups.
• The payment rate for each of
the 18 diagnostic groups was the average allowed amount per day
over all the ICD-9-CM codes in a diagnosis group, based upon the claim’s
primary diagnosis, plus an add-on to reimburse for capital costs.
4.4.3.2 For services provided on or
after the mandated date, as directed by HHS, for ICD-10 implementation:
• A rate setting methodology
utilizing the first alpha character and two digits of a primary
diagnosis code.
• Eighteen diagnosis groupings
were defined and designed based upon the groupings and definitions
contained in the ICD-10-CM publication. For example, Group 1 is
defined as ICD-10-CM codes A00 to B99, or Infectious and Parasitic
Diseases. The first alpha character and two digits of a primary
diagnosis code are utilized for placement into one of the 18 groups.
• The payment rate for each of
the 18 diagnostic groups was the average allowed amount per day over
all the ICD-10-CM codes in a diagnosis group, based upon the claim’s
primary diagnosis, plus an add-on to reimburse for capital costs.
4.4.3.3 Group payments were calculated
by dividing total allowed charges by total inpatient days for the
group.
4.4.3.4 Once the 18 groupings were
defined, certain unique admissions were identified for reimbursement
separately from the 18 groupings. These are listed
in Figure 1.34-3.
4.5 Payments
4.5.1 General. For services provided
before the mandated date, as directed by HHS, for ICD-10 implementation,
the per diem group payment rate will be based upon the first three
digits of the primary diagnosis code. For services provided on or
after the mandated date, as directed by HHS, for ICD-10 implementation,
the per diem group payment rate will be based upon the first alpha
character and two digits of the primary diagnosis code. The maximum
amount allowed by TRICARE and the amount reimbursed for hospital
inpatient care shall be the lesser of:
• Actual billed charges for hospital
inpatient care; or
• The U.S. National per diem
rate authorized under TRICARE, multiplied by the country specific
index factor, is the country specific hospital per diem. This per
diem is multiplied by the number of covered days of hospital inpatient
care and equals the maximum amount allowed by TRICARE to be paid
for the episode on inpatient care.
4.5.2 Only the primary diagnosis
code, on the date of admission, will be taken into consideration when
determining the group for a payment rate. Only one payment group
can be assigned to each independent episode of inpatient care. For
services provided before the mandated date, as directed by HHS,
for ICD-10 implementation, each institutional claim for service
reimbursement must contain a valid ICD-9-CM code or narrative description
of services, and must be used to represent the primary diagnosis
for inpatient admission. For services provided on or after the mandated
date, as directed by HHS, for ICD-10 implementation, each institutional
claim for service reimbursement must contain a valid ICD-10-CM code
or narrative description of services, and must be used to represent
the primary diagnosis for inpatient admission. If a valid diagnosis
code or narrative description is not supplied by the institutional
provider it must be developed and supported by the overseas claims
processor. Development of an institutional claim shall contain the
necessary elements to satisfy TRICARE Encounter Data (TED) editing
system requirements.
4.6 Beneficiary - Change in Eligibility
Status
Since
payment is on a per diem basis, the hospital claim for services
shall be paid for the days the beneficiary is TRICARE eligible and
denied for the days the beneficiary is not TRICARE eligible.
4.7 Beneficiary Cost-Shares
Inpatient cost-shares as contained
in
Chapter 2, Sections 1 and
2,
for non-Diagnosis Related Group (DRG) facilities shall be applicable
to the hospital allowable charge authorized under TRICARE.
4.8 Updating Payment Rates
4.8.1 Additions, changes, revisions,
or deletions to the diagnosis codes or country specific index shall
be communicated to the overseas claims processor and be considered
as routine updates to this payment system and processed under TRICARE
Operations Manual (TOM),
Chapter 1, Section 4, paragraph 2.4.
4.8.2 Inpatient per diem rates for
Panama and the Philippines will be updated annually in conjunction
with the TRICARE DRG update in the U.S.
4.9 The overseas claims processor
shall maintain the current year and two immediate past years’ iterations
of the U.S. National per diems authorized under TRICARE and the
country specific index factors.
4.10 There is no TRICARE waiver
process applicable to hospitals in specified locations outside the
50 U.S. and the District of Columbia for institutional inpatient
rates.
Figure 1.34-1 Country
Specific Index Factors
|
|
Country Specific Index Factor
|
Effective
|
|
2008
|
|
Philippines
|
0.52
|
November 1, 2008
|
|
Panama
|
0.70
|
February 1, 2009
|
|
2012
|
|
Philippines
|
0.57
|
December 1, 2012
|
|
Panama
|
0.70
|
December 1, 2012
|
Figure 1.34-2 Institutional
Inpatient Diagnostic Groupings For Specified Locations Outside The
50 U.S. And The District Of Columbia - National Inpatient Per Diem
Amounts
|
Group
|
Description
|
ICD-9-CM
Code Range
(FOR
SERVICES BEFORE the mandated date, as directed by HHS, for ICD-10 implementation)
|
ICD-10-CM
CODE RANGE
(FOR
SERVICES ON OR AFTER the mandated date, as directed by HHS, for
ICD-10 implementation)
|
National Inpatient Per
Diem
|
|
|
|
October
1, 2020
|
|
01
|
Infection Disease
|
1 - 139
|
A00 - B99
|
$3,057
|
|
02
|
Cancer
|
140 - 239
|
C00 - D49
|
$4,694
|
|
03
|
Endocrine
|
240 - 289
|
D50 - D89, E00
- E89
|
$3658
|
|
04
|
Mental health
|
290 - 319
|
F01 - F99
|
$1,326
|
|
05
|
Nervous System
|
320 - 389
|
G00 - G99, H00
- H95
|
$3,217
|
|
06
|
Circulatory
|
390 - 459
|
I00 - I99
|
$4,645
|
|
07
|
Respiratory
|
460 - 519
|
J00 - J99
|
$2,409
|
|
08
|
Digestive
|
520 - 579
|
K00 - K95
|
$2,877
|
|
09
|
Genitourinary
|
580 - 629
|
N00 - N99
|
$2,982
|
|
10
|
Pregnancy, birth
(mother)
|
630 - 679, V22
- V24, V27
|
O00 - O9A, Z33,
Z34, Z36, Z37, Z39
|
$1,978
|
|
11
|
Musculoskeletal
and skin
|
680-739
|
L00 - L99, M00
- M99
|
$8,021
|
|
12
|
Congenital abnormalities
|
740 - 759
|
Q00 - Q99
|
$6,619
|
|
13
|
Perinatal Fetus
and infant
|
760 - 779, V21,
V29 - V39
|
P0 - P96, Z3A,
Z38
|
$1,518
|
|
14
|
Signs, Symptoms,
etc
|
780 - 799
|
R00 - R99
|
$2,706
|
|
15
|
Injuries
|
800 - 959
|
S00 - T34
|
$4,635
|
|
16
|
Poisoning
|
960 - 996
|
T36 - T79
|
$2,780
|
|
17
|
Complications
|
996 - 999
|
T80 - T88
|
$4,077
|
|
18
|
All other codes
|
|
|
$3,210
|
|
OCTOBER
1, 2021
|
|
01
|
Infection Disease
|
1 - 139
|
A00 - B99
|
$3,069
|
|
02
|
Cancer
|
140 - 239
|
C00 - D49
|
$4,947
|
|
03
|
Endocrine
|
240 - 289
|
D50 - D89, E00
- E89
|
$3,908
|
|
04
|
Mental health
|
290 - 319
|
F01 - F99
|
$1,425
|
|
05
|
Nervous System
|
320 - 389
|
G00 - G99, H00
- H95
|
$3,203
|
|
06
|
Circulatory
|
390 - 459
|
I00 - I99
|
$4,779
|
|
07
|
Respiratory
|
460 - 519
|
J00 - J99
|
$2,689
|
|
08
|
Digestive
|
520 - 579
|
K00 - K95
|
$3,028
|
|
09
|
Genitourinary
|
580 - 629
|
N00 - N99
|
$3,134
|
|
10
|
Pregnancy, birth
(mother)
|
630 - 679, V22
- V24, V27
|
O00 - O9A, Z33,
Z34, Z36, Z37, Z39
|
$2,064
|
|
11
|
Musculoskeletal
and skin
|
680-739
|
L00 - L99, M00
- M99
|
$7,840
|
|
12
|
Congenital abnormalities
|
740 - 759
|
Q00 - Q99
|
$5,856
|
|
13
|
Perinatal Fetus
and infant
|
760 - 779, V21,
V29 - V39
|
P0 - P96, Z3A,
Z38
|
$1,710
|
|
14
|
Signs, Symptoms,
etc
|
780 - 799
|
R00 - R99
|
$2,778
|
|
15
|
Injuries
|
800 - 959
|
S00 - T34
|
$5,191
|
|
16
|
Poisoning
|
960 - 996
|
T36 - T79
|
$2,476
|
|
17
|
Complications
|
996 - 999
|
T80 - T88
|
$4,196
|
|
18
|
All other codes
|
|
|
$3,273
|
|
October
1, 2022
|
|
01
|
Infection Disease
|
1 - 139
|
A00 - B99
|
$3,307
|
|
02
|
Cancer
|
140 - 239
|
C00 - D49
|
$4,711
|
|
03
|
Endocrine
|
240 - 289
|
D50 - D89, E00
- E89
|
$4,411
|
|
04
|
Mental health
|
290 - 319
|
F01 - F99
|
$1,453
|
|
05
|
Nervous System
|
320 - 389
|
G00 - G99, H00
- H95
|
$3,381
|
|
06
|
Circulatory
|
390 - 459
|
I00 - I99
|
$4,898
|
|
07
|
Respiratory
|
460 - 519
|
J00 - J99
|
$2,565
|
|
08
|
Digestive
|
520 - 579
|
K00 - K95
|
$3,014
|
|
09
|
Genitourinary
|
580 - 629
|
N00 - N99
|
$3,099
|
|
10
|
Pregnancy, birth
(mother)
|
630 - 679, V22
- V24, V27
|
O00 - O9A, Z33,
Z34, Z36, Z37, Z39
|
$2,158
|
|
11
|
Musculoskeletal
and skin
|
680-739
|
L00 - L99, M00
- M99
|
$7,288
|
|
12
|
Congenital abnormalities
|
740 - 759
|
Q00 - Q99
|
$5,426
|
|
13
|
Perinatal Fetus
and infant
|
760 - 779, V21,
V29 - V39
|
P0 - P96, Z3A,
Z38
|
$1,751
|
|
14
|
Signs, Symptoms,
etc
|
780 - 799
|
R00 - R99
|
$2,826
|
|
15
|
Injuries
|
800 - 959
|
S00 - T34
|
$4,725
|
|
16
|
Poisoning
|
960 - 995
|
T36 - T79
|
$2,712
|
|
17
|
Complications
|
996 - 999
|
T80 - T88
|
$3,783
|
|
18
|
All other codes
|
|
|
$3,220
|
Figure 1.34-2 Unique
Admissions - National Inpatient Per Diem Amounts
|
Description
|
ICD-9-CM
Code
(For Services before
the mandated date, as directed by HHS, for ICD-10 implementation)
|
ICD-10-CM
Code
(For Services on
or after the mandated date, as directed by HHS, for
ICD-10 implementation)
|
National Inpatient Per
Diem
|
|
|
|
October
1, 2020
|
|
Heart Transplant
|
V42.1
|
Z94.1
|
$9,331
|
|
Kidney Transplant
|
V42.0
|
Z94.0
|
$8,354
|
|
Combined Small
Intestine/Liver (SI/L) Transplant
|
V42.7
|
Z94.4
|
$8,384
|
|
Lung Transplant
|
V42.6
|
Z94.2
|
$5,505
|
|
Simultaneous Pancreas-Kidney
(SPK) Transplant
|
V42.89
|
Z94.89
|
$5,965
|
|
Pancreas Transplant
|
V42.83
|
Z94.83
|
$7,365
|
|
Coronary Artery
Bypass Grafts ((CABG)
|
V43.4
|
Z95.828
|
$6,665
|
|
Coronary Bypass
with Percutaneous Transluminal Coronary Angioplasty (PTCA)
|
V45.82
|
Z98.61
|
$7,933
|
|
October
1, 2021
|
|
Heart Transplant
|
V42.1
|
Z94.1
|
$8,746
|
|
Kidney Transplant
|
V42.0
|
Z94.0
|
$9,369
|
|
Combined Small
Intestine/Liver (SI/L) Transplant
|
V42.7
|
Z94.4
|
$7,315
|
|
Lung Transplant
|
V42.6
|
Z94.2
|
$5,944
|
|
Simultaneous Pancreas-Kidney
(SPK) Transplant
|
V42.89
|
Z94.89
|
$6,121
|
|
Pancreas Transplant
|
V42.83
|
Z94.83
|
$7,552
|
|
Coronary Artery
Bypass Grafts (CABG)
|
V43.4
|
Z95.828
|
$6,991
|
|
Coronary Bypass
with Percutaneous Transluminal Coronary Angioplasty (PTCA)
|
V45.82
|
Z98.61
|
$9,345
|
|
October
1, 2022
|
|
Heart Transplant
|
V42.1
|
Z94.1
|
$8,192
|
|
Kidney Transplant
|
V42.0
|
Z94.0
|
$8,698
|
|
Combined Small
Intestine/Liver (SI/L) Transplant
|
V42.7
|
Z94.4
|
$6,842
|
|
Lung Transplant
|
V42.6
|
Z94.2
|
$6,126
|
|
Simultaneous Pancreas-Kidney
(SPK) Transplant
|
V42.89
|
Z94.89
|
$6,048
|
|
Pancreas Transplant
|
V42.83
|
Z94.83
|
$7,461
|
|
Coronary Artery
Bypass Grafts (CABG)
|
V43.4
|
Z95.828
|
$7,487
|
|
Coronary Bypass
with Percutaneous Transluminal Coronary Angioplasty (PTCA)
|
V45.82
|
Z98.61
|
$10,083
|