Reasonable Charges for Inpatient DRG and SNF Medical Services; 2005 Calendar Year Update

AGENCY:

Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

Section 17.101 of Title 38 of the Code of Federal Regulations sets forth the Department of Veterans Affairs (VA) medical regulations concerning “reasonable charges” for medical care or services provided or furnished by VA to a veteran:

• For a nonservice-connected disability for which the veteran is entitled to care (or the payment of expenses of care) under a health plan contract;
• For a nonservice-connected disability incurred incident to the veteran's employment and covered under a worker's compensation law or plan that provides reimbursement or indemnification for such care and services; or
• For a nonservice-connected disability incurred as a result of a motor vehicle accident in a State that requires automobile accident reparations insurance.

The regulations include methodologies for establishing billed amounts for the following types of charges: Acute inpatient facility charges; skilled nursing facility/sub-acute inpatient facility charges; partial hospitalization facility charges; outpatient facility charges; physician and other professional charges, including professional charges for anesthesia services and dental services; pathology and laboratory charges; observation care facility charges; ambulance and other emergency transportation charges; and charges for durable medical equipment, drugs, injectables, and other medical services, items, and supplies identified by Healthcare Common Procedure Coding System (HCPCS) Level II codes. The regulations also provide that data for calculating actual charge amounts at individual VA facilities based on these methodologies will either be published in a notice in the Federal Register or will be posted on the Internet site of the Veterans Health Administration Chief Business Office, currently at http://www.va.gov/cbo,, under “Charge Data.” Certain of these charges are hereby updated as described in the SUPPLEMENTARY INFORMATION section of this notice. These changes are effective on January 1, 2005.

When charges for medical care or services provided or furnished at VA expense by either VA or non-VA providers have not been established under other provisions of the regulations, the method for determining VA's charges is set forth at 38 CFR 17.101(a)(8).

FOR FURTHER INFORMATION CONTACT:

Romona Greene, Chief Business Office (168), Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 254-0361. (This is not a toll free number.)

SUPPLEMENTARY INFORMATION:

Of the charge types listed in the Summary section of this notice, only the acute inpatient facility charges and skilled nursing facility/sub-acute inpatient facility charges are being changed. Charges for the following charge types: Partial hospitalization facility charges; outpatient facility charges; physician and other professional charges, including professional charges for anesthesia services and dental services; pathology and laboratory charges; observation care facility charges; ambulance and other emergency transportation charges; and charges for durable medical equipment, drugs, injectables, and other medical services, items, and supplies identified by HCPCS Level II codes are not being changed. These Outpatient facility charges and Professional charges remain the same as set forth in a notice published in the Federal Register on April 15, 2004 (69 FR 20118).

Based on the methodologies set forth in 38 CFR 17.101, this document provides an update to acute inpatient charges based on 2005 DRGs. Acute inpatient facility charges by diagnosis related group (DRG) are set forth in Table A in the December 19, 2003, Federal Register notice. Table A in the December 19 notice document is being replaced by Table A in this notice, which provides updated charges based on 2005 DRGs.

Also, this document provides for an updated skilled nursing facility/sub-acute inpatient facility all-inclusive per diem charge that, using the methodologies set forth in 38 CFR 17.101, is adjusted by a geographic area factor based on the location where the care is provided. The skilled nursing facility/sub-acute inpatient facility per diem charge is set forth in Table B in the October 2, 2003, Federal Register notice. Table B in the October 2 notice document is being replaced by Table B in this notice, which provides the updated all-inclusive nationwide skilled nursing facility/sub-acute inpatient facility per diem charge.

The charges in this update for acute inpatient facility and skilled nursing facility/sub-acute inpatient facility services are effective on January 1, 2005.

In this update, we are retaining the table designations used for acute inpatient facility charges by DRGs in the notice published in the Federal Register on December 19, 2003 (68 FR 70867). We also are retaining the table designation used for skilled nursing facility/sub-acute inpatient facility charges in the notice published in the Federal Register on October 2, 2003 (68 FR 56892). Accordingly, the tables identified as being updated by this notice correspond to the applicable tables published in the December 19 and October 2 notices, beginning with Table A through Table B.

We have updated the list of data sources presented in Supplementary Table 1 to reflect the updated data sources used to establish the updated charges described in this notice.

We have also updated the list of VA medical facility locations. As a reminder, in Supplementary Table 3 published in the Federal Register dated April 15, 2004, we set forth the list of VA medical facility locations, which includes their three-digit ZIP Codes and provider-based/non-provider-based designations. In accordance with the final rule, subsequent updates to Supplementary Table 3 will be posted on the Internet site of the Veterans Health Administration Chief Business Office.

Consistent with the regulations, the updated data tables and supplementary tables containing the changes described in this notice are published with this notice and will be posted on the Internet site of the Veterans Health Administration Chief Business Office, currently at http://www.va.gov/cbo,, under “Charge Data.”