[Federal Register Volume 66, Number 148 (Wednesday, August 1, 2001)]
[Rules and Regulations]
[Pages 39828-40102]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-18868]



[[Page 39827]]

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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Parts 405, 410, 412, et al.



Medicare Program; Changes to the Hospital Inpatient Prospective Payment 
Systems and Rates and Costs of Graduate Medical Education; Fiscal Year 
2002 Rates, Etc.; Final Rules

  Federal Register / Vol. 66, No. 148 / Wednesday, August 1, 2001 / 
Rules and Regulations  

[[Page 39828]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 410, 412, 413, 482, 485, and 486

[CMS 1131-F, CMS 1158-F, and CMS 1178-F]
RINs 0938-AK20; 0938-AK73; and 0938-AK74


Medicare Program; Changes to the Hospital Inpatient Prospective 
Payment Systems and Rates and Costs of Graduate Medical Education: 
Fiscal Year 2002 Rates; Provisions of the Balanced Budget Refinement 
Act of 1999; and Provisions of the Medicare, Medicaid, and SCHIP 
Benefits Improvement and Protection Act of 2000

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final rules.

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SUMMARY: We are revising the Medicare hospital inpatient prospective 
payment systems for operating and capital costs to: implement 
applicable statutory requirements, including a number of provisions of 
the Medicare, Medicaid, and SCHIP [State Children's Health Insurance 
Program] Benefits Improvement and Protection Act of 2000 (Public Law 
106-554); and implement changes arising from our continuing experience 
with these systems. In addition, in the Addendum to this final rule, we 
describe changes to the amounts and factors used to determine the rates 
for Medicare hospital inpatient services for operating costs and 
capital-related costs. These changes apply to discharges occurring on 
or after October 1, 2001. We also set forth the rate-of-increase limits 
as well as policy changes for hospitals and hospital units excluded 
from the prospective payment systems.
    We are making changes to the policies governing payments to 
hospitals for the direct costs of graduate medical education and 
critical access hospitals.
    Lastly, we are responding to public comments received on the 
following two related interim final rules that we published in the 
Federal Register and finalizing those interim rules:
     An August 1, 2000 interim final rule with comment period 
(65 FR 47026, HCFA-1131-IFC) that implemented, or conformed the 
regulations to, certain statutory provisions relating to Medicare 
payments to hospitals for inpatient services that were contained in the 
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 
(Public Law 106-113), and that were effective during FY 2000. These 
provisions related to reclassification of hospitals from urban to rural 
status, reclassification of certain hospitals for purposes of payment 
during fiscal year 2000, critical access hospitals, payments to 
hospitals excluded from the prospective payment system, and payments 
for indirect and direct graduate medical education costs.
     A June 13, 2001 interim final rule with comment period (66 
FR 32172, HCFA-1178-IFC) that implemented, or conformed the regulations 
to, certain statutory provisions relating to Medicare payments to 
hospitals for inpatient services that were contained in Public Law 106-
554, and that were effective prior to passage of Public Law 106-554 on 
December 21, 2000; on April 1, 2001; or on July 1, 2001. Many of the 
provisions of Public Law 106-554 modified changes to the Social 
Security Act made by Public Law 106-113 or the Balanced Budget Act of 
1997 (Public Law 105-33), or both.

EFFECTIVE DATE: The provisions of this final rule are effective October 
1, 2001. This rule is a major rule as defined in 5 U.S.C. 804(2). 
Pursuant to 5 U.S.C. 801(a)(1)(A), we are submitting a report to 
Congress on this rule on August 1, 2001.

FOR FURTHER INFORMATION CONTACT: Stephen Phillips, (410) 786-4548, 
Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage 
Index, Hospital Geographic Reclassifications, Sole Community Hospitals, 
Disproportionate Share Hospitals, and Medicare-Dependent, Small Rural 
Hospitals Issues; Tzvi Hefter, (410) 786-4487, Capital Prospective 
Payment, Excluded Hospitals, Graduate Medical Education and Critical 
Access Hospitals Issues.

SUPPLEMENTARY INFORMATION:

Availability of Copies and Electronic Access

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I. Background

A. Summary

    Section 1886(d) of the Social Security Act (the Act) sets forth a 
system of payment for the operating costs of acute care hospital 
inpatient stays under Medicare Part A (Hospital Insurance) based on 
prospectively set rates. Section 1886(g) of the Act requires the 
Secretary to pay for the capital-related costs of hospital inpatient 
stays under a prospective payment system. Under these prospective 
payment systems, Medicare payment for hospital inpatient operating and 
capital-related costs is made at predetermined, specific rates for each 
hospital discharge. Discharges are classified according to a list of 
diagnosis-related groups (DRGs). Each DRG has a payment weight assigned 
to it, based on the average resources used to treat Medicare patients 
in that DRG.
    Under section 1886(d)(1)(B) of the Act in effect without 
consideration of the amendments made by Public Law 105-33, Public Law 
106-113, and Public Law 106-554, certain specialty hospitals are 
excluded from the hospital inpatient prospective payment system: 
psychiatric hospitals and units, rehabilitation hospitals and units, 
children's hospitals, long-term care hospitals, and cancer hospitals. 
For these hospitals and units, Medicare payment for operating costs is 
based on reasonable costs subject to a hospital-specific annual limit, 
until the payment provisions of Public Laws 105-33, 106-113, and 106-
554 that are applicable to three classes of these hospitals are 
implemented, as discussed below.

[[Page 39829]]

    Various sections of Public Laws 105-33, 106-113, and 106-554 
provide for the transition of rehabilitation hospitals and units, 
psychiatric hospitals and units, and long-term care hospitals from 
being paid on an excluded hospital basis to being paid on an individual 
prospective payment system basis. These provisions are as follows:
     Rehabilitation Hospitals and Units. Section 1886(j) of the 
Act, as added by section 4421 of Public Law 105-33 and amended by 
section 125 of Public Law 106-113 and section 305 of Public Law 106-
554, authorizes the implementation of a prospective payment system for 
inpatient hospital services furnished by rehabilitation hospitals and 
units. Section 4421 of Public Law 105-33 amended the Act by adding 
section 1886(j). Section 1886(j) of the Act provides for a fully 
implemented prospective payment system for inpatient rehabilitation 
hospitals and rehabilitation units, effective for cost reporting 
periods beginning during or after October 2002, with payment provisions 
during a transitional period based on target amounts specified in 
section 1886(b) of the Act. Section 125 of Public Law 106-113 amended 
section 1886(j) of the Act to require the Secretary to use a discharge 
as the payment unit for inpatient rehabilitation services under the 
prospective payment system and to establish classes of patient 
discharges by functional-related groups. Section 305 of Public Law 106-
554 further amended section 1886(j) of the Act to allow hospitals to 
elect to be paid the full Federal prospective payment rather than the 
transitional period payments specified in the Act. A final rule 
implementing the prospective payment system for inpatient 
rehabilitation hospitals will be published in the Federal Register 
shortly.
     Psychiatric Hospitals and Units. Sections 124(a) and (c) 
of Public Law 106-113 provide for the development of a per diem 
prospective payment system for payment for inpatient hospital services 
of psychiatric hospitals and units under the Medicare program, 
effective for cost reporting periods beginning on or after October 1, 
2002. This system must include an adequate patient classification 
system that reflects the differences in patient resource use and costs 
among these hospitals and must maintain budget neutrality. We are in 
the process of developing a proposed rule, to be followed by a final 
rule, to implement the prospective payment system for psychiatric 
hospitals and units, effective for October 1, 2002.
     Long-Term Care Hospitals. Sections 123(a) and (c) of 
Public Law 106-113 provide for the development of a per discharge 
prospective payment system for payment for inpatient hospital services 
furnished by long-term care hospitals under the Medicare program, 
effective for cost reporting periods beginning on or after October 1, 
2002. Section 307(b)(1) of Public Law 106-554 provides that payments 
under the long-term care prospective payment system will be made on a 
prospective payment basis rather than a cost basis. The long-term care 
hospital prospective payment system must include a patient 
classification system that reflects the differences in patient resource 
use and costs, and must maintain budget neutrality. We are planning to 
develop a proposed rule, to be followed by a final rule, to implement 
the prospective payment system for long-term care hospitals, effective 
for October 1, 2002. Section 307 of Public Law 106-554 provides that if 
the Secretary is unable to develop a prospective payment system for 
long-term care hospitals that can be implemented by October 1, 2002, 
the Secretary must implement a prospective payment system that bases 
payment under the system using the existing acute hospital DRGs, 
modified where feasible to account for resource use of long-term care 
hospital patients using the most recently available hospital discharge 
data for long-term care services.
    Under sections 1820 and 1834(g) of the Act, payments are made to 
critical access hospitals (CAHs) (that is, rural hospitals or 
facilities that meet certain statutory requirements) for inpatient and 
outpatient services on a reasonable cost basis. Reasonable cost is 
determined under the provisions of section 1861(v)(1)(A) of the Act and 
existing regulations under Parts 413 and 415.
    Under section 1886(a)(4) of the Act, costs of approved educational 
activities are excluded from the operating costs of inpatient hospital 
services. Hospitals with approved graduate medical education (GME) 
programs are paid for the direct costs of GME in accordance with 
section 1886(h) of the Act; the amount of payment for direct GME costs 
for a cost reporting period is based on the hospital's number of 
residents in that period and the hospital's costs per resident in a 
base year.
    The regulations governing the acute care hospital inpatient 
prospective payment system are located in 42 CFR part 412. The 
regulations governing excluded hospitals and hospital units are located 
in Parts 412 and 413. The regulations governing GME payments are 
located in Part 413. The regulations governing CAHs are located in 
Parts 413 and 485.
    This final rule implements amendments enacted by Public Law 106-554 
relating to updates to FY 2002 payments for hospital inpatient 
services, hospitals' geographic reclassifications and wage indexes, GME 
costs, the payment adjustment for disproportionate share hospitals 
(DSHs), the indirect medical education (IME) adjustment for teaching 
hospitals, and CAHs. It also implements other changes affecting DRG 
classifications and relative weights, annual updates to the data used 
to calculate the wage index, sole community hospitals (SCHs), payments 
under the inpatient capital prospective payment system, and policies 
related to hospitals and units excluded from the prospective payment 
system. These changes are addressed in sections II., III., IV., and VI. 
of this preamble.
    Section 533 of Public Law 106-554 requires the Secretary to 
establish a mechanism to recognize the costs of new medical services 
and technologies by October 1, 2001. We proposed a mechanism in the May 
4, 2001 proposed rule. We received 61 comments on our proposed criteria 
to qualify for this special payment and on the proposed mechanism to 
pay for qualifying new technologies. Due to this large number of 
comments, we will publish a separate final rule to respond to comments 
received on our proposal, and to establish a mechanism, by October 1, 
2001.
    Although we intend to establish the mechanism by October 1, 2001, 
we will not make additional payments under the mechanism for cases 
involving new technology during FY 2002 because it is not feasible. 
This is due to the timing of the enactment of Public Law 106-554 on 
December 21, 2000, the requirement that we establish the mechanism 
through notice and an opportunity for public comment, and the 
requirement that the payments be implemented in a budget neutral 
manner. That is, it was not feasible to establish the criteria by which 
new technologies would qualify through a proposed rule with opportunity 
for public comment as part of the May 4, 2001 proposed rule, finalize 
those criteria in response to public comments, allow technologies to 
qualify under those criteria, and implement payments for any qualified 
technologies in a budget neutral manner. This is because making the 
special payments in a budget neutral manner requires an adjustment to 
the standardized amounts (which must be published in final by August 1 
each year).

[[Page 39830]]

    Representatives of new technologies seeking to qualify for special 
payments under this provision for FY 2003 should proceed with their 
application by contacting us at the telephone numbers listed in the 
``For Further Information Contact'' section of this preamble. As 
indicated previously, a final rule containing the specific qualifying 
criteria and payment mechanism will be published shortly.
    This final rule also responds to public comments on, and finalizes 
implementation of, provisions of Public Law 106-113 that relate to 
Medicare payments to hospitals for FY 2001 that were addressed in a 
separate interim final rule with comment period (HCFA-1131-IFC), 
published in the Federal Register on August 1, 2000 (65 FR 47026).
    Lastly, this final rule responds to public comments on, and 
finalizes implementation of, other provisions of Public Law 106-554 
that relate to Medicare payments to hospitals effective prior to 
October 1, 2001 (that is, for FY 2001 or for the period between April 
l, 2001 and September 30, 2001) that were addressed in a separate 
interim final rule with comment period (HCFA-1178-IFC), published in 
the Federal Register on June 13, 2001 (66 FR 32172).
    In summary, this final rule responds to public comments on, and 
finalizes, three documents published in the Federal Register: The 
August 1, 2000 interim final rule with comment period, the May 4, 2001 
proposed rule (HCFA-1158-P), and the June 13, 2001 interim final rule 
with comment period, as discussed below.
    The charts below specify the effective dates of the various 
provisions of Public Law 106-113 and Public Law 106-554.

Effective Dates of the Provisions of Public Law 106-113 Included in This
                               Final Rule
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         Section No.                  Title            Effective date
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111.........................  Indirect Medical      10/01/1999.
                               Education
                               Adjustment Formula.
121.........................  Wage Adjustment to    10/01/1999.
                               Caps on Target
                               Amounts for
                               Excluded Hospitals
                               and Units.
152(a)......................  Reclassified          10/01/1999.
                               Hospitals in
                               Certain Designated
                               Counties.
153.........................  Calculation of Wage   10/01/1999.
                               Index for
                               Hattiesburg,
                               Mississippi.
154.........................  Calculation of Wage   10/01/1999.
                               Index for Allentown-
                               Bethlehem-Easton,
                               Pennsylvania MSA.
312.........................  Initial Residency     7/01/2000, for
                               Period for Child      residency programs
                               Neurology Residency   that began before,
                               Programs.             on, or after 11/29/
                                                     1999.
401(a)......................  Reclassification of   01/01/2000.
                               Certain Urban
                               Hospitals to Rural.
401(b)(2)...................  Application of        01/01/2000.
                               Reclassifications
                               under Section
                               401(a) to Critical
                               Access Hospitals.
403(a)......................  Length of Stay        11/29/1999.
                               Restrictions on
                               Inpatient Stays in
                               Critical Access
                               Hospitals.
403(b)......................  Qualifications of     11/29/1999.
                               For-Profit
                               Hospitals for
                               Critical Access
                               Hospital Status.
403(c)......................  Qualification of      11/29/1999 for
                               Closed Hospitals or   hospitals that
                               Hospitals Downsized   closed after 11/29/
                               to Health Clinics     1989; 11/29/1999
                               for Critical Access   for hospitals that
                               Hospital              downsized to health
                               Designation.          clinics.
403(e)......................  Elimination of        11/29/1999.
                               Medicare Part B
                               Deductible and
                               Coinsurance for
                               Clinical Diagnostic
                               Laboratory Tests
                               Furnished in
                               Critical Access
                               Hospitals.
403(f)......................  Provisions on Swing-  11/29/1999.
                               Beds in Critical
                               Access Hospitals.
404.........................  Extension of          10/01/2002 through 9/
                               Medicare-Dependent,   30/2006.
                               Small Rural
                               Hospital Program.
407(a)......................  Residents on          11/29/1999.
                               Approved Leaves of
                               Absence--GME and
                               IME.
407(b)......................  Expansion of Number   04/01/2000.
                               of Unweighted
                               Residents in Rural
                               Hospitals--GME and
                               IME.
407(c)......................  Urban Hospitals with  04/01/2000.
                               Rural Training
                               Tracks or
                               Integrated Rural
                               Tracks--GME and IME.
407(d)......................   Residents Training   10/01/1997
                               at Certain Veterans
                               Hospitals--GME and
                               IME.
408(a)......................  Swing Beds for        07/01/1998 through
                               Skilled Nursing       the end of the
                               Facility Level of     facility's third
                               Care Patients.        cost reporting
                                                     period after this
                                                     date.
408(b)......................  Elimination of        07/01/1998 through
                               Constraints on        the end of the
                               Length of Stay in     facility's third
                               Swing Beds in Rural   cost reporting
                               Hospitals.            period after this
                                                     date.
541.........................  Additional Payments   01/01/2000.
                               to Hospitals for
                               Approved Nursing
                               and Allied Health
                               Education to
                               Reflect Utilization
                               of Medicare+Choice
                               Enrollees.
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               Effective Dates of the Provisions of Public Law 106-113 Included in This Final Rule
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           Section No.                     Title                               Effective date
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201.............................  Clarification of No      11/29/1999.
                                   Beneficiary Cost-
                                   Sharing for Clinical
                                   Diagnostic Laboratory
                                   Tests Furnished by
                                   Critical Access
                                   Hospitals.
202.............................  Assistance with Fee      07/01/2001.
                                   Schedule Payment for
                                   Professional Services
                                   under All-Inclusive
                                   Rate.
211.............................  Threshold for            04/01/2001.
                                   Disproportionate Share
                                   Hospitals.

[[Page 39831]]

 
212.............................  Option to Base           04/01/2001.
                                   Eligibility for
                                   Medicare-Dependent,
                                   Small Rural Hospital
                                   Program on Discharges
                                   during Two of the
                                   Three Most Recently
                                   Audited Cost Reporting
                                   Periods.
213.............................  Extension of Option to   10/01/2000.
                                   use Rebased Target
                                   Amounts to All Sole
                                   Community Hospitals.
301.............................  Revision of Acute Care   04/01/2001.
                                   Hospital Payment
                                   Update for 2001.
302.............................  Additional Modification  04/01/2001.
                                   in Transition for
                                   Indirect Medical
                                   Education Adjustment.
303.............................  Decrease in Reductions   04/01/2001.
                                   for Disproportionate
                                   Share Hospitals.
304(a)..........................  Three-Year Wage Index    10/01/2001.
                                   Reclassifications; Use
                                   of 3 Years of Wage
                                   Data for Evaluating
                                   Reclassifications.
304(b)..........................  Statewide Wage Index     10/01/2001 for reclassification beginning 10/01/2002.
                                   for Reclassifications.
304(c)..........................  Collection of            09/30/2003 for application 10/1/2004.
                                   Occupational Case Mix
                                   Data.
306.............................  Payment for Inpatient    10/01/2000.
                                   Services of
                                   Psychiatric Hospitals.
307.............................  Payment for Inpatient    10/01/2000.
                                   Services of Long-Term
                                   Care Hospitals.
511.............................  Increase in Floor for    10/01/2001.
                                   Payments for Direct
                                   Costs of Graduate
                                   Medical Education.
512.............................  Change in Distribution   01/01/2001.
                                   Formula for
                                   Medicare+Choice-
                                   Related Nursing and
                                   Allied Health
                                   Education Costs.
541.............................  Increase in              10/01/2000.
                                   Reimbursement for Bad
                                   Debt.
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B. Summary of the Provisions of the May 4, 2001 Proposed Rule

    On May 4, 2001, we published a proposed rule in the Federal 
Register (66 FR 22646) that set forth proposed changes to the Medicare 
hospital inpatient prospective payment system for operating and 
capital-related costs for FY 2002. We set forth proposed changes to the 
amounts and factors used in determining the rates for these costs. In 
addition, we proposed changes relating to payments for GME costs and 
payments to excluded hospitals and units, SCHs, and CAHs.
    The following is a summary of the major changes that we proposed 
and the issues we addressed in the May 4, 2001 proposed rule:
1. Changes to the DRG Reclassifications and Recalibrations of Relative 
Weights
    As required by section 1886(d)(4)(C) of the Act, we proposed annual 
adjustments to the DRG classifications and relative weights. Based on 
analyses of Medicare claims data, we proposed to establish a number of 
new DRGs and make changes to the designation of diagnosis and procedure 
codes under other existing DRGs for FY 2002.
    We also addressed the provisions of section 533 of Public Law 106-
544 regarding development of a mechanism for increased payment for new 
medical services and technologies and the required report to Congress 
on expeditiously introducing new medical services and technology into 
the DRGs.
2. Changes to the Hospital Wage Index
    We proposed to use wage data taken from hospitals' FY 1998 cost 
reports in the calculation of the FY 2002 wage index. We also proposed 
to implement the third year of the phaseout of wage costs related to 
GME or Part A certified registered nurse anesthetists (CRNA) from the 
FY 2002 wage index calculation.
    We proposed several changes to the wage index methodology that 
would apply in calculating the FY 2003 wage index, and addressed new 
procedures for requesting wage data corrections and a modification of 
the process and timetable for updating the wage index.
     We also discussed the collection of hospital occupational 
mix data as required by section 304(c) of Public Law 106-554.
     In addition, we discussed revisions to the wage index 
based on hospital redesignations and reclassifications for purposes of 
the wage index, including changes to reflect the provisions of sections 
304(a) and (b) of Public Law 106-554 relating to 3-year wage index 
reclassifications by the MGCRB, the use of 3 years of wage data for 
evaluating reclassification requests for FYs 2003 and later, and the 
application of a statewide wage index for reclassifications beginning 
in FY 2003.
3. Other Decisions and Changes to the Prospective Payment System for 
Inpatient Operating and Graduate Medical Education Costs
    We discussed several provisions of the regulations in 42 CFR parts 
412 and 413 and set forth certain proposed changes concerning SCHs; 
rural referral centers; changes relating to the IME adjustment as a 
result of section 302 of Public Law 106-554; changes relating to the 
DSH adjustment as a result of section 303 of Public Law 106-554; the 
establishment of policies relating to the 3-year application of wage 
index reclassifications by the MGCRB, the use of 3 years of wage data 
in evaluating reclassification requests to the MGCRB for FYs 2003 and 
later, and the use of a statewide wage index for reclassifications 
beginning in FY 2003, as required by sections 304(a) and (b) of Public 
Law 106-554.
    We discussed proposed requirements for qualifying for additional 
payments for new medical services and technology, as required by 
section 533(b) of Public Law 106-554.
    Lastly, we proposed changes relating to payment for the direct 
costs of GME, including changes as a result of section 511 of Public 
Law 106-554.
4. Prospective Payment System for Capital-Related Costs
    We proposed payment requirements for capital-related costs, 
including the special exceptions payment, beginning October 1, 2001.
5. Proposed Changes for Hospitals and Hospital Units Excluded from the 
Prospective Payment Systems
    We discussed the following proposals concerning excluded hospitals 
and hospital units and CAHs:
     Limits on and adjustments to the proposed target amounts 
for FY 2002.
     Revision of the methodology for wage neutralizing the 
hospital-specific target amounts using preclassified wage data.
     Updated caps for new excluded hospitals and units as well 
as changes

[[Page 39832]]

in the effective date of classifications of excluded hospitals and 
units.
     The prospective payment system for inpatient 
rehabilitation hospitals and units.
     Payments to CAHs, including exclusion from the payment 
window requirements; the availability of CRNA pass-through payments; 
payment for emergency room on-call physicians; treatment of ambulance 
services; the use of certain qualified practitioners for preanesthesia 
and postanesthesia evaluations; and clarification of location 
requirements for CAHs.
6. Determining Prospective Payment Operating and Capital Rates and 
Rate-of-Increase Limits
    In the Addendum to the proposed rule, we set forth proposed changes 
to the amounts and factors for determining the FY 2002 prospective 
payment rates for operating costs and capital-related costs. We also 
proposed threshold amounts for outlier cases. In addition, we proposed 
update factors for determining the rate-of-increase limits for cost 
reporting periods beginning in FY 2002 for hospitals and hospital units 
excluded from the prospective payment system.
7. Impact Analysis
    In Appendix A, we set forth an analysis of the impact of the 
proposed changes on affected entities.
8. Capital Acquisition Model
    In Appendix B of the proposed rule, we set forth the technical 
appendix on the proposed FY 2002 capital cost model.
9. Report to Congress on the Update Factor for Hospitals under the 
Prospective Payment System and Hospitals and Units Excluded From the 
Prospective Payment System
    In Appendix C of the proposed rule, as required by section 
1886(e)(3) of the Act, we set forth our report to Congress on our 
initial estimate of a recommended update factor for FY 2002 for 
payments to hospitals included in the prospective payment systems, and 
hospitals excluded from the prospective payment systems.
10. Recommendation of Update Factor for Hospital Inpatient Operating 
Costs
    In Appendix D, as required by sections 1886(e)(4) and (e)(5) of the 
Act, we included our recommendation of the appropriate percentage 
change for FY 2002 for the following:
     Large urban area and other area average standardized 
amounts (and hospital-specific rates applicable to SCHs and Medicare-
dependent, small rural hospitals) for hospital inpatient services paid 
for under the prospective payment system for operating costs.
     Target rate-of-increase limits to the allowable operating 
costs of hospital inpatient services furnished by hospitals and 
hospital units excluded from the prospective payment system.
11. Discussion of Medicare Payment Advisory Commission Recommendations
    In the proposed rule, we discussed recommendations by the Medicare 
Payment Advisory Commission (MedPAC) concerning hospital inpatient 
payment policies and presented our responses to those recommendations. 
Under section 1805(b) of the Act, MedPAC is required to submit a report 
to Congress, not later than March 1 of each year, that reviews and 
makes recommendations on Medicare payment policies. We respond to those 
recommendations in section VII. of this preamble. For further 
information relating specifically to the MedPAC March 1 report or to 
obtain a copy of the report, contact MedPAC at (202) 653-7220 or visit 
MedPAC's website at: www.medpac.gov.
12. Public Comments Received in Response to the May 4, 2001 Proposed 
Rule
    We received a total of 232 timely items of correspondence 
containing multiple comments on the proposed rule. Major issues 
addressed by the commenters included: additional payments for new 
medical services and technologies, geographic reclassifications of 
hospitals for purposes of the wage index, DRG reclassifications, 
payments for GME, and payments to CAHs.
    Summaries of the public comments received and our responses to 
those comments are set forth below under the appropriate heading, with 
the exception of comments and responses pertaining to specific payments 
for new technologies under section 533 of Public Law 106-554. As 
described previously, this provision will be implemented through a 
separate final rule.

C. Summary of the Provisions of the August 1, 2000 Interim Final Rule 
with Comment Period

    On August 1, 2000, we published in the Federal Register (65 FR 
47026) an interim final rule with comment period that implemented, or 
conformed the regulations to, certain statutory provisions relating to 
Medicare payments to hospitals for inpatient services that were 
contained in Public Law 106-113, that were effective for FY 2000. The 
following is a summary of the policy changes we implemented as a result 
of Public Law 106-113:
1. Changes Relating to Payments for Operating Costs Under the Hospital 
Inpatient Prospective Payment System
     Reclassification of Certain Counties. We implemented the 
provisions of section 152(a) of Public Law 106-113 that reclassified 
hospitals in certain designated counties for purposes of making 
payments to affected hospitals under section 1886(d) of the Act for FY 
2000. The counties affected by this provision are identified under 
section III. of this preamble.
     Wage Index. We implemented sections 153 and 154 of Public 
Law 106-113 that contain provisions affecting the wage indexes of 
specific Metropolitan Statistical Areas (MSA). Under section 153, the 
Hattiesburg, Mississippi FY 2000 wage index was calculated including 
wage data from Wesley Medical Center. Under section 154, the Allentown-
Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was calculated 
including wage data for Lehigh Valley Hospital.
     Reclassification of Certain Urban Hospitals as Rural 
Hospitals. We implemented section 401 of Public Law 106-113 which 
directed the Secretary to treat certain hospitals located in urban 
areas as being located in rural areas of their State if the hospital 
meets statutory criteria and files an application with HCFA. This 
provision was effective on January 1, 2000.
     IME Adjustment. We implemented section 111 of Public Law 
106-113 which provided for an additional payment to teaching hospitals 
equal to the additional amount the hospitals would have been paid for 
FY 2000 if the IME adjustment formula (which reflects the higher 
indirect operating costs associated with GME) for FY 2000 had remained 
the same as for FY 1999.
     Extension of the MDH Provision. We implemented section 404 
of Public Law 106-113 which extended the MDH program and its current 
payment methodology for an additional 5 years, from FY 2002 through FY 
2006.
2. Additional Changes Relating to Direct GME and IME
     Initial Residency Period for Child Neurology Residency 
Programs. We implemented section 312 of Public Law 106-113 which 
provides that in determining the number of residents for purposes of 
GME and IME payments, the period of board eligibility and the initial 
residency period for child neurology is the period of board

[[Page 39833]]

eligibility for pediatrics plus 2 years. This provision is effective on 
or after July 1, 2000, for residency programs that began before, on, or 
after November 29, 1999.
     Residents on Approved Leaves of Absence. We implemented 
section 407(a) of Public Law 106-113 which provides that, for purposes 
of determining a hospital's full-time equivalent (FTE) cap for direct 
GME payments and the IME adjustment, a hospital may count an individual 
to the extent that the individual would have been counted as a primary 
care resident for purposes of the FTE cap but for the fact that the 
individual was on maternity or disability leave or a similar approved 
leave of absence. The provision relating to direct GME was effective 
with cost reporting periods beginning on or after November 29, 1999. 
The provision relating to the IME adjustment applied to discharges 
occurring in cost reporting periods beginning on or after November 29, 
1999.
     Expansion of Number of Unweighted Residents in Rural 
Hospitals. We implemented section 407(b) of Public Law 106-113 which 
provides that a rural hospital's resident FTE count for direct GME and 
IME may not exceed 130 percent of the number of unweighted residents 
that the rural hospital counted in its most recent cost reporting 
period ending on or before December 31, 1996. The provision relating to 
direct GME applied to cost reporting periods beginning on or after 
April 1, 2000. The provision relating to the IME adjustment applied to 
discharges occurring on or after April 1, 2000.
     Urban Hospitals with Rural Training Tracks or Integrated 
Rural Tracks. We implemented section 407(c) of Public Law 106-113 which 
allows an urban hospital that establishes separately accredited 
approved medical residency training programs (or rural training tracks) 
in a rural area or has an accredited training program with an 
integrated rural track to receive an FTE cap adjustment for purposes of 
direct GME and IME. The provision was effective with cost reporting 
periods beginning on or after April 1, 2000, for direct GME, and with 
discharges occurring on or after April 1, 2000, for IME.
     Residents Training at Certain Veterans Affairs Hospitals. 
We implemented section 407(d) of PublicLaw 106-113 which provides that 
a non-Veterans Affairs (VA) hospital may receive a temporary adjustment 
to its FTE cap to reflect residents who were training at a VA hospital 
and were transferred on or after January 1, 1997, and before July 31, 
1998, to the non-VA hospital because the program at the VA hospital 
would lose its accreditation by the Accreditation Council on Graduate 
Medical Education if the residents continued to train at the facility. 
This provision applies as if it was included in the enactment of Public 
Law 105-33, that is, for direct GME, with cost reporting periods 
beginning on or after October 1, 1997, and for IME, for discharges 
occurring on or after October 1, 1997. If a hospital is owed payments 
as a result of this provision, payments must be made immediately.
3. Payments for Nursing and Allied Health Education: Utilization of 
Medicare+Choice Enrollees
    We implemented section 541 of Public Law 106-113 which provides an 
additional payment to hospitals that receive payments under section 
1861(v) of the Act for approved nursing and allied health education 
programs associated with services to Medicare+Choice enrollees. This 
provision is effective for portions of cost reporting periods occurring 
on or after January 1, 2000.
4. Changes Relating to Hospitals and Hospital Units Excluded From the 
Prospective Payment System
    We implemented section 121 of Public Law 106-113 which amended 
section 1886(b)(3)(H) of the Act to direct the Secretary to provide for 
an appropriate wage adjustment to the caps on the target amounts for 
psychiatric hospitals and units, rehabilitation hospitals and units, 
and long-term care hospitals for cost reporting periods beginning on or 
after October 1, 1999.
5. Changes Relating to CAHs
    We implemented--
     Section 401(b) of Public Law 106-113, which contained 
conforming changes to incorporate the reclassifications made by section 
401(a) of Public Law 106-113 to the CAH statute (section 
1820(c)(2)(B)(i) of the Act). This provision is effective beginning on 
January 1, 2000.
     Section 403(a) of Public Law 106-113, which deleted the 
96-hour length of stay restriction on inpatient care in a CAH and 
authorized a period of stay that does not exceed, on an annual, average 
basis, 96 hours per patient. This provision is effective beginning on 
November 29, 1999.
     Section 403(b) of Public Law 106-113, which allows for-
profit hospitals to qualify for CAH status. This provision is effective 
beginning on November 29, 1999.
     Section 403(c) of Public Law 106-113, which allows 
hospitals that have closed within 10 years prior to November 29, 1999, 
or hospitals that downsized to a health clinic or health center, to be 
designated as CAHs if they satisfy the established criteria for 
designation, other than the requirement for existing hospital status.
     Section 403(e) of Public Law 106-113, which eliminated the 
Medicare Part B deductible and coinsurance for clinical diagnostic 
laboratory tests furnished by a CAH on an outpatient basis. This 
provision is effective with respect to services furnished on or 
afterNovember 29, 1999.
     Section 403(f) of Public Law 106-113, entitled 
``Participation in Swing Bed Program,'' which amended sections 
1883(a)(1) and (c) of the Act.
6. Changes Relating Hospital to Swing Bed Program
    We implemented section 408(a) of Public Law 106-113 which 
eliminated the requirement for a hospital to obtain a certification of 
need to use acute care beds as swing beds for skilled nursing facility 
(SNF) level of care patients; and section 408(b) of Public Law 106-113 
which eliminates constraints on the length of stay in swing beds for 
rural hospitals with 50 to 100 beds. These provisions were effective on 
the first day after the expiration of the transition period for 
prospective payments for covered SNF services under the Medicare 
program (that is, at the end of the transition period for the SNF 
prospective payments system that began with the facility's first cost 
reporting period beginning on or after July 1, 1998 and extend through 
the end of the facility's third cost reporting period after this date).
    We received a total of eight timely items of correspondence 
containing multiple comments on the August 1, 2000 interim final rule 
with comment period. Summaries of the public comments received and our 
responses to those comments are set forth below under the appropriate 
section headings of this final rule.

D. Summary of the Provisions of the June 13, 2001 Interim Final Rule 
With Comment Period

    On June 13, 2001, we published an interim final rule with comment 
period in the Federal Register (66 FR 32172) that implemented changes 
to the Act affecting Medicare payments to hospitals for inpatient 
services that were made by Public Law 106-554. Some of these changes 
were effective before the December 21, 2000 date of enactment of Public 
Law 106-554, on April 1, 2001,

[[Page 39834]]

or on July 1, 2001. The changes, on which we requested public comment, 
are as follows:
1. Changes Relating to Payments for Operating Costs Under the Hospital 
Inpatient Prospective Payment System
     Treatment of Rural and Small Urban Disproportionate Share 
Hospitals (DSHs) . We implemented the provisions of section 211 of 
Public Law 106-554 which lowered thresholds by which certain classes of 
hospitals qualify for DSH payments, with respect to discharges 
occurring on or after April 1, 2001.
     Decrease in Reductions for DSH Payments. We implemented 
section 303 of Public Law 106-554 which modified the previous reduction 
in the DSH payment to be 2 percent in FY 2001 and 3 percent in FY 2002.
     Medicare-Dependent, Small Rural Hospitals (MDHs). We 
implemented section 212 of Public Law 106-554 which provided an option 
to base eligibility for MDH status on discharges during two of the 
three most recently audited cost reporting periods, effective with cost 
reporting periods beginning on or after April 1, 2001.
     Revision of Prospective Payment System Standardized 
Amounts. We implemented section 301 of Public Law 106-554 which revised 
the update factor increase for the inpatient prospective payment rates 
for FY 2001.
     Indirect Medical Education Adjustment (IME). We 
implemented section 302 of Public Law 106-554 which provided that for 
the purposes of making the IME payment for discharges occurring on or 
after April 1, 2001 and before October 1, 2001, the adjustment will be 
determined as if the adjustment equaled a 6.75 percent increase in 
payment for every 10 percent increase in the resident-to-bed ratio, 
rather than a 6.25 percent increase.
     SCHs. We implemented section 213 of Public Law 106-554 
which further extended the 1996 rebasing option, for hospital cost 
reporting periods beginning October 1, 2000, to all SCHs and provides 
that this extension is effective as if it had been included in section 
405 of Public Law 106-113.
2. Payments for Nursing and Allied Health Education: Utilization of 
Medicare+Choice Enrollees
    We implemented section 512 of Public Law 106-554 which revised the 
formula for determining the additional payment amounts to hospitals for 
Medicare+Choice nursing and allied health education costs to 
specifically account for each hospital's Medicare+Choice utilization.
3. Changes Relating to Payments for Capital-Related Costs Under the 
Hospital Inpatient Prospective Payment System
    As a result of implementing section 301 of Public Law 106-554, 
which provided increased inpatient operating payment rates, we 
recalculated the unified outlier threshold for inpatient operating and 
inpatient capital-related costs. Therefore, we revised the capital 
outlier offset which also required us to revise the capital-related 
rates.
4. Changes Relating to Hospitals and Hospital Units Excluded From the 
Prospective Payment System
     Increase in the Incentive Payment for Excluded Psychiatric 
Hospitals and Units. We implemented section 306 of Public Law 106-554, 
which provided that for cost reporting periods beginning on or after 
October 1, 2000, for psychiatric hospitals and units, if the allowable 
net inpatient operating costs do not exceed the hospital's ceiling, 
payment is the lower of: (1) net inpatient operating costs plus 15 
percent of the difference between inpatient operating costs and the 
ceiling; or, (2) net inpatient costs plus 3 percent of the ceiling.
     Increase in the Wage Adjusted 75th Percentile Cap on the 
Target Amounts for Long-Term Care Hospitals. We implemented section 
307(a) of Public Law 106-554, which provided a 2-percent increase to 
the wage-adjusted 75th percentile cap on the target amount for long-
term care hospitals, effective for cost reporting periods beginning 
during FY 2001.
     Increase in the Target Amounts for Long-Term Care 
Hospitals. We implemented section 307(a) Public Law 106-554, which 
provided a 25 percent increase to the target amounts for long-term care 
hospitals for cost reporting periods beginning in FY 2001, up to the 
cap on target amounts.
5. Changes Relating to CAHs
     Elimination of Coinsurance for Clinical Diagnostic 
Laboratory Tests Furnished by a CAH. We implemented section 201(a) of 
Public Law 106-554, which amended section 1834(g) of the Act to state 
that there will be no collection of coinsurance, deductible, 
copayments, or any other type of cost sharing from Medicare 
beneficiaries with respect to outpatient clinical diagnostic laboratory 
services furnished as outpatient CAH services and that those services 
will be paid for on a reasonable cost basis.
     Assistance with Fee Schedule Payment for Professional 
Services under All-Inclusive Rate. We implemented section 202 of Public 
Law 106-554, which amended section 1834(g)(2)(B) of the Act to provide 
that when a CAH elects to be paid for Medicare outpatient services 
under the reasonable costs for facility services plus fee schedule 
amounts for professional services method, Medicare will pay 115 percent 
of the amount it otherwise pays for the professional services.
     Condition of Participation with Hospital Requirements at 
the Time of Application for CAH Designation (Sec. 485.612). We 
implemented a conforming change to correct Sec. 485.612 to reflect that 
certain entities are not required to have a provider agreement prior to 
CAH designation.
6. Other Inpatient Costs
     Increase in Reimbursement for Bad Debts. We implemented 
section 541 of Public Law 106-554 which provided a 30 percent decrease 
of allowable hospital bad debt reimbursement for cost reporting periods 
beginning during FY 2001 and all subsequent fiscal years. This section 
modified section 4451 of Public Law 105-33 that reduced the total 
allowable bad debt reimbursement for hospitals by 45 percent.
    We received a total of 13 timely pieces of correspondence 
containing comments on the June 13, 2001 interim final rule with 
comment period. A summary of these public comments and our responses to 
them are set forth under sections IV. and VI. of this final rule.

II. Changes to DRG Classifications and Relative Weights

A. Background

    Under the prospective payment system, we pay for inpatient hospital 
services on a rate per discharge basis that varies according to the DRG 
to which a beneficiary's stay is assigned. The formula used to 
calculate payment for a specific case multiplies an individual 
hospital's payment rate per case by the weight of the DRG to which the 
case is assigned. Each DRG weight represents the average resources 
required to care for cases in that particular DRG relative to the 
average resources used to treat cases in all DRGS.
    Congress recognized that it would be necessary to recalculate the 
DRG relative weights periodically to account for changes in resource 
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires 
that the Secretary adjust the DRG classifications and relative weights 
at least annually. These adjustments are made to reflect changes

[[Page 39835]]

in treatment patterns, technology, and any other factors that may 
change the relative use of hospital resources. Changes to the DRG 
classification system and the recalibration of the DRG weights for 
discharges occurring on or after October 1, 2001 are discussed below.

B. DRG Reclassification

1. General
    Cases are classified into DRGs for payment under the prospective 
payment system based on the principal diagnosis, up to eight additional 
diagnoses, and up to six procedures performed during the stay, as well 
as age, sex, and discharge status of the patient. The diagnosis and 
procedure information is reported by the hospital using codes from the 
International Classification of Diseases, Ninth Revision, Clinical 
Modification (ICD-9-CM). Medicare fiscal intermediaries enter the 
information into their claims processing systems and subject it to a 
series of automated screens called the Medicare Code Editor (MCE). 
These screens are designed to identify cases that require further 
review before classification into a DRG.
    After screening through the MCE and any further development of the 
claims, cases are classified into the appropriate DRG by the Medicare 
GROUPER software program. The GROUPER program was developed as a means 
of classifying each case into a DRG on the basis of the diagnosis and 
procedure codes and demographic information (that is, sex, age, and 
discharge status). It is used both to classify past cases in order to 
measure relative hospital resource consumption to establish the DRG 
weights and to classify current cases for purposes of determining 
payment. The records for all Medicare hospital inpatient discharges are 
maintained in the Medicare Provider Analysis and Review (MedPAR) file. 
The data in this file are used to evaluate possible DRG classification 
changes and to recalibrate the DRG weights.
    In version 18 of the GROUPER (used for FY 2001), cases are assigned 
to one of 499 DRGs (including one DRG (469) for a diagnosis that is 
invalid as a discharge diagnosis and one DRG (470) for ungroupable 
diagnoses) in 25 major diagnostic categories (MDCs). Most MDCs are 
based on a particular organ system of the body. For example, MDC 6 is 
Diseases and Disorders of the Digestive System. However, some MDCs are 
not constructed on this basis because they involve multiple organ 
systems (for example, MDC 22 (Burns)).
    In general, cases are assigned to an MDC, based on the principal 
diagnosis, before assignment to a DRG. However, there are six DRGs to 
which cases are directly assigned on the basis of procedure codes. 
These are the DRGs for heart, liver, bone marrow, and lung transplants 
(DRGs 103, 480, 481, and 495, respectively) and the two DRGs for 
tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs 
before classification to an MDC.
    Within most MDCs, cases are then divided into surgical DRGs and 
medical DRGs. Surgical DRGs are based on a hierarchy that orders 
individual procedures or groups of procedures by resource intensity. 
Medical DRGs generally are differentiated on the basis of diagnosis and 
age. Some surgical and medical DRGs are further differentiated based on 
the presence or absence of complications or comorbidities (CC).
    Generally, the GROUPER does not consider other procedures. That is, 
nonsurgical procedures or minor surgical procedures generally not 
performed in an operating room are not listed as operating room (OR) 
procedures in the GROUPER decision tables. However, there are a few 
non-OR procedures that do affect DRG assignment for certain principal 
diagnoses, such as extracorporeal shock wave lithotripsy for patients 
with a principal diagnosis of urinary stones.
    We proposed numerous changes to the DRG classification system for 
FY 2002. The proposed changes, the public comments we received 
concerning them, and the final DRG changes are set forth below. Unless 
otherwise noted, the changes we are implementing will be effective in 
the revised GROUPER software (Version 19.0) to be implemented for 
discharges on or after October 1, 2001. Unless noted otherwise, we are 
relying on the data analysis in the proposed rule for the changes 
discussed here.
    Chart 1 lists the changes we are making by adding new DRGs or 
removing old DRGs. Chart 2 summarizes the changes we are making with 
respect to the reassignment of procedure codes. Chart 3 presents the 
changes we are making to the titles of existing DRGs.
    In Chart 2 of the proposed rule, several procedure codes were 
erroneously included in the ``Removed from DRG'' column of the chart 
(66 FR 22650). The 11 affected codes are 37.21, 37.22, 37.23, 37.26, 
88.52, 88.53, 88.54, 88.55, 88.56, 88.57, and 88.58. Inclusion of these 
codes in this chart made it appear as if the codes were being deleted 
from DRG 104. In fact, they are being additionally assigned to DRG 514. 
We have corrected Chart 2 in this final rule.

                                 Chart 1.--Summary of Changes in DRG Assignments
----------------------------------------------------------------------------------------------------------------
                        Diagnosis related groups (DRGs)                           Added as new       Removed
----------------------------------------------------------------------------------------------------------------
Pre-MDC:
    DRG 512 (Simultaneous Pancreas/Kidney Transplant).........................               X   ...............
    DRG 513 (Pancreas Transplants)............................................               X   ...............
MDC 5 (Diseases and Disorders of the Circulatory System):
    DRG 112 (Percutaneous Cardiovascular Procedures)..........................  ...............               X
    DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization)......               X   ...............
    DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization)...               X   ...............
    DRG 516 (Percutaneous Cardiovascular Procedures with Acute Myocardial                    X   ...............
     Infarction (AMI))........................................................
    DRG 517 (Percutaneous Cardiovascular Procedures without AMI, with Coronary               X   ...............
     Artery Stent Implant.....................................................
    DRG 518 (Percutaneous Cardiovascular Procedures without AMI, without                     X   ...............
     Coronary Artery Stent Implant............................................
MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective
 Tissue):
    DRG 519 (Cervical Spinal Fusion with CC)..................................               X   ...............
    DRG 520 (Cervical Spinal Fusion without CC)...............................               X   ...............
MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders):
    DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other          ...............               X
     Symptomatic Treatment with CC)...........................................
    DRG 435 (Alcohol/Drug Abuse or Dependency, Detoxification or Other          ...............               X
     Symptomatic Treatment without CC)........................................
    DRG 436 (Alcohol/Drug Dependence with Rehabilitation Therapy).............  ...............               X
    DRG 437 (Alcohol/Drug Dependence, Combined Rehabilitation and               ...............               X
     Detoxification Therapy)..................................................
    DRG 521 (Alcohol/Drug Abuse or Dependence with CC)........................               X   ...............

[[Page 39836]]

 
    DRG 522 (Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation                X   ...............
     Therapy).................................................................
    DRG 523 (Alcohol/Drug Abuse or Dependence without CC, without                            X   ...............
     Rehabilitation Therapy)..................................................
----------------------------------------------------------------------------------------------------------------


     Chart 2.--Summary of Assignment or Reassignment of Diagnosis or
                    Procedure Codes in Existing DRGs
------------------------------------------------------------------------
   Diagnosis/procedure codes      Removed from DRG    Reassigned to DRG
------------------------------------------------------------------------
 MDC 5 (Diseases and Disorders
   of the CirculatorySystem)
------------------------------------------------------------------------
Principal Diagnosis Code:
    410.01  Acute myocardial     116..............  516.
     infarction of
     anterolateral wall,
     initial episode of care.
    410.11  Acute myocardial     116..............  516.
     infarction of other
     anterior wall, initial
     episode of care.
    410.21  Acute myocardial     116..............  516.
     infarction of
     inferolateral wall,
     initial episode of care.
    410.31  Acute myocardial     116..............  516.
     infarction of
     inferoposterior wall,
     initial episode of care.
    410.41  Acute myocardial     116..............  516.
     infarction of other
     inferior wall, initial
     episode of care.
    410.51  Acute myocardial     116..............  516.
     infarction of other
     lateral wall, initial
     episode of care.
    410.61  True posterior wall  116..............  516.
     infarction, initial
     episode of care.
    410.71  Subendocardial       116..............  516.
     infarction, initial
     episode of care.
    410.81  Acute myocardial     116..............  516.
     infarction of other
     specified sites, initial
     episode of care.
    410.91  Acute myocardial     116..............  516
     infarction of unspecified
     site, initial episode of
     care.
Procedure Codes:
    37.94  Implantation or       104, 105.........  514, 515.
     replacement of automatic
     cardioverter/
     defibrillation, total
     system (AICD).
    37.95  Implantation of       104, 105.........  514, 515.
     automatic cardioverter/
     defibrillator lead(s) only.
    37.96  Implantation of       104, 105.........  514, 515.
     automatic cardioverter/
     defibrillator pulse
     generator only.
    37.97  Raplacement of        104, 105.........  514, 515.
     automatic cardioverter/
     defibrilator lead(s) only;.
    37.98  Replacement of        104, 105.........  514, 515.
     automatic cardioverter/
     defibrillator pulse
     generator only.
Operating Room Procedures:
    35.96  Percutaneous          112, 116.........  516, 517, 518.
     valvuloplasty.
    36.01  Single vessel         112, 116.........  516, 517, 518.
     percutaneous transluminal
     coronary angioplasty
     (PTCA) or coronary
     atherectomy without
     mention of thrombolytic
     agent.
    36.02  Single vessel         112, 116.........  516, 517, 518.
     percutaneous transluminal
     coronary angioplasty
     (PTCA) or coronary
     atherectomy with mention
     of thrombolytic agent.
    36.05  Multiple vessel       112, 116.........  516, 517, 518.
     percutaneous transluminal
     coronary angioplasty
     (PTCA) or coronary
     atherectomy performed
     during the same operation,
     with or without mention of
     thrombolytic agent.
    36.09  Other removal of      112, 116.........  516, 517, 518.
     coronary artery
     obstruction.
    37.34  Catheter ablation of  112, 116.........  516, 517, 518.
     lesion or tissues of heart.
    92.27  Implantation or       non-OR in MDC-5..  517
     insertion of radioactive
     elements.
Nonoperating Room Procedures:
    36.06  Insertion of          116..............  517.
     coronary artery stent(s).
    37.26 Cardiac                112..............  514, 516, 517, 518.
     electrophysiologic
     stimulation and recording
     studies.
    37.27  Cardiac mapping.....  112..............  516, 517, 518.
------------------------------------------------------------------------
 MDC 8 (Diseases and Disorders
 of the Musculoskeletal System
     and Connective Tissue)
------------------------------------------------------------------------
Procedure Codes:
    81.02  Other cervical        497, 498.........  519, 520.
     fusion, anterior technique.
    81.03  Other cervical        497, 498.........  519, 520.
     fusion, posterior
     technique.
   MDC 15 (Newborns and Other
    Neonates with Conditions
  Originating in the Perinatal
            Period)
Diagnosis Codes:
    770.7  Chronic respiratory   387, 389.........  92, 93.
     disease arising in the
     perinatal period.
    773.0  Hemolytic disease     387, 389.........  390.
     due to RH isoimmunization.
    773.1  Hemolytic disease     387, 389.........  390.
     due to ABO isoimmunization.
Secondary Diagnosis Codes:
    478.1  Other diseases of     390..............  391.
     nasal cavity and sinuses.
    520.6  Disturbances in       390..............  391.
     tooth eruption.
    623.8  Other specified       390..............  391.
     noninflammatory disorders
     of vagina.
    709.00  Dyschromia,          390..............  391.
     unspecified.
    709.01  Vitiglio...........  390..............  391.
    709.09  Dyschromia, Other..  390..............  391.
    744.1  Accessory Auricle...  390..............  391.
    754.61  Congenital pes       390..............  391.
     planus.
    757.33  Congenital           390..............  391.
     pigmentary anomalies of
     skin.
    757.39  Other specified      390..............  391.
     anomaly of skin.
    764.08  ``Light for dates''  390..............  391.
     without mention of fetal
     malnutrition, 2,000-2,499
     grams.
    764.98  Fetal growth         390..............  391.
     retardation, unspecified,
     2,000-2,499 grams.
    772.6  Cutaneous hemorrhage  390..............  391.
    779.3  Feeding problems in   390..............  391
     newborns.
    794.15  Abnormal and         390..............  391.
     auditory function studies.

[[Page 39837]]

 
    796.4  Other abnormal        390..............  391.
     clinical findings.
    V20.2  Routine infant or     390..............  391.
     child health check.
    V72.1  Examination of ears   390..............  391.
     and hearing.
------------------------------------------------------------------------


                                                           Chart 3.--Summary of Retitled DRGs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                  MDC                          DRG No.               Current name                                    New name
--------------------------------------------------------------------------------------------------------------------------------------------------------
MDC 5.................................  DRG 116               Other Permanent Cardiac    Other Cardiac Pacemaker Implantation.
                                                               Pacemaker Implantation,
                                                               or PTCA, with Coronary
                                                               Artery Stent Implant.
MDC 8.................................  DRG 497               Spinal Fusion with CC....  Spinal Fusion except Cervical with CC.
MDC 8.................................  DRG 498               Spinal Fusion without CC.  Spinal Fusion except Cervical with CC.
--------------------------------------------------------------------------------------------------------------------------------------------------------

2. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Removal of Defibrillator Cases from DRGs 104 and 105
    DRGs 104 (Cardiac Valve & Other Major Cardiothoracic Procedures 
with Cardiac Catheterization) and 105 (Cardiac Valve & Other Major 
Cardiothoracic Procedures without Cardiac Catheterization) include the 
replacement or open repair of one or more of the four heart valves. 
These valves may be diseased or damaged, resulting in either leakage or 
restriction of blood flow to the heart, compromising the ability of the 
heart to pump blood. This procedure requires the use of a heart-lung 
bypass machine, as the heart must be stilled and opened to repair or 
replace the valve.
    Cardiac defibrillators are implanted to correct episodes of 
fibrillation (very fast heart rate) caused by malfunction of the 
conduction mechanism of the heart. Through implanted cardiac leads, the 
defibrillator mechanism senses changes in heart rhythm. When very fast 
heart rates occur, the defibrillator produces a burst of electric 
current through the leads to restore the normal heart rate. An 
implanted defibrillator constantly monitors heart rhythm. The 
implantation of this device does not require the use of a heart-lung 
bypass machine, and would be expected to be very different in terms of 
resource usage, although both procedures currently group to DRGs 104 
and 105.
    For the proposed rule, as part of our ongoing review of DRGs, we 
examined Medicare claims data on DRG 104 and DRG 105. We reviewed 100 
percent of the FY 2000 MedPAR file containing hospital bills received 
through May 31, 2000, for discharges in FY 2000, and found that the 
average charges across all cases in DRG 104 were $84,060, while the 
average charges across all cases in DRG 105 were $66,348. Carving out 
code 37.94 (Implantation or replacement of automatic cardioverter/
defibrillator, total system [AICD]) from DRGs 104 and 105 increased 
those average charges to $91,366 for DRG 104 and $67,323 for DRG 105. 
We identified 11,021 defibrillator cases in DRG 104 (out of 25,112 
total cases), with average charges of $74,719, and 2,434 defibrillator 
cases in DRG 105 (out of 20,094 total cases), with average charges of 
$59,267.
    We performed additional review on cases containing code 37.95 
(Implantation of automatic cardioverter/defibrillator lead(s) only) 
with code 37.96 (Implantation of automatic cardioverter/defibrillator 
pulse generator only) and on cases containing code 37.97 (Replacement 
of automatic cardioverter/defibrillator lead(s) only) with code 37.98 
(Replacement of automatic cardioverter/defibrillator pulse generator 
only). This subgrouping contained only 56 patients. The average charges 
for the 18 patients in DRG 104 were $58,847. The average charges for 
the 38 patients in DRG 105 were $54,891.
    In the proposed rule, because we believed the defibrillator cases 
are significantly different from other cases in DRGs 104 and 105, we 
proposed two new DRGs: DRG 514 (Cardiac Defibrillator Implant with 
Cardiac Catheterization) and DRG 515 (Cardiac Defibrillator Implant 
without Cardiac Catheterization).
    We also proposed the removal of procedure codes 37.94, 37.95 and 
37.96, and 37.97 and 37.98 from DRGs 104 and 105 to form the new DRGs 
514 and 515.
    We received 58 comments on this proposal.
    Comment: Many commenters noted that implanted cardioverter 
defibrillators (ICDs) or AICDs are lifesaving devices that demonstrate 
state-of-the-art technology for the treatment of cardiac arrhythmias by 
continuously monitoring, analyzing, and, if needed, restoring a 
patient's normal heart rhythm.
    One commenter described the technology. Similar to the size of a 
pacemaker, the ICD is placed under the skin of the upper chest. It has 
the capacity to continuously monitor and analyze a patient's heart 
rhythm. If the ICD detects an arrhythmia, it can terminate the abnormal 
rhythm with either a pacemaker function or the delivery of a low-energy 
electrical shock to restore normal heart rhythm.
    Response: We agree that ICDs and AICDs are an important addition to 
the treatment of cardiac disease. The creation of DRGs 514 and 515 is 
not meant to effect a judgement call about the efficacy or importance 
of this treatment, but simply to attempt to improve the accuracy of 
payments within MDC 5, based on the actual charge data associated with 
these cases.
    Comment: A vast majority of the commenters expressed concern that 
payments associated with defibrillators will decrease for FY 2002 as a 
result of this change, with some commenters noting that an ICD or AICD 
may cost the hospital between $22,000 and $25,000 per device. The 
commenters stated that if this is the case, there is a limited amount 
for the remainder of the hospital care (for example, operating room, 
supplies, nursing staff salary, and typically a 7-day stay in an 
intensive care unit). Most commenters called for

[[Page 39838]]

additional analysis prior to implementation of DRGs 514 and 515.
    Response: As we described in the proposed rule and above, DRGs 104 
and 105 currently include many different procedures, with a range of 
costs associated with these different procedures. We proposed to change 
the assignment of cardiac defibrillators to new DRGs 514 and 515 to 
more accurately pay for the more expensive procedures remaining in DRGs 
104 and 105, as well as to improve the payment accuracy for cardiac 
defibrillators. In fact, the relative weight of DRG 104 increases from 
FY 2001 to FY 2002 by 9.1 percent.
    Comment: Many commenters argued that using hospital charges to 
determine DRG relative weights can give a distorted picture of the 
costs of a procedure. The commenters referred to an unspecified 
national database indicating that the average mark-up of charges over 
cost for ICDs is lower than the mark-up applied to other components of 
care. Other commenters referred to the March 2001 Report to Congress by 
the MedPAC, which, in the context of evaluating available data for 
setting accurate relative values, stated that hospitals' billed charges 
``give a distorted picture of relative costliness across DRGs because 
they reflect systematic differences among hospitals in the average 
mark-up of charges over costs'' (page 11).
    Several commenters stated that about 66 percent of hospitals are 
losing $5,000 or more per case for these procedures. These commenters 
did not understand why payment would be reduced even further in light 
of those losses.
    Response: Hospital charges have been the basis for recalibrating 
the DRG relative weights since FY 1986 (see 50 FR 24372 and 50 FR 
35652). To the extent that the mark-up of charges over costs varies 
from one particular device or procedure to another, the relative 
weights will be impacted. However, due to the relativity of the DRG 
weights, a low mark-up associated with one device or procedure will be 
offset by relatively higher mark-ups associated with another device or 
procedure, leading to higher relative weights, and thus higher 
payments, for the latter device or procedure. The prospective payment 
system is an average-based payment methodology, where hospitals are 
expected to offset any losses they may incur from any individual or 
group of cases with payment gains incurred from other cases.
    Furthermore, hospital charges are determined by each hospital on an 
item-by-item basis. It is not possible to account for these individual 
management decisions in the process of developing a national payment 
system based on prospectively determined average payment rates.
    As demonstrated in the impact analysis in Appendix A to this final 
rule, hospital payments would rise (prior to the budget neutrality 
adjustment) by 0.3 percent as a result of all of the DRG changes we are 
implementing in this final rule, including this change. In addition, we 
note that the latest analysis by MedPAC indicates the average hospital 
Medicare inpatient operating margin during FY 1999 (the latest year 
available) was 12.0 percent (Report to the Congress: Medicare Payment 
Policy, page 64). Therefore, we believe that hospitals will be able to 
adequately adjust to these payment changes in both the short and the 
long term.
    Comment: One commenter noted that the adjustment to DRGs 104 and 
105 as reflected in Table 5, ``List of Diagnosis Related Groups (DRGs), 
Relative Weighting Factors, Geometric and Arithmetic Mean Length of 
Stay,'' in the Addendum of the proposed rule, does not reflect the 
resource consumption as discussed above. The commenter recommended that 
we increase the relative weights to reflect the resource consumption of 
DRGs 104 and 105.
    Response: In this final rule, the relative weight for DRG 104 is 
7.8411 for FY 2002, an increase of 9.1 percent from FY 2001. The 
relative weight for DRG 105 in this final rule is 5.6796 for FY 2002, a 
0.4 percent increase from FY 2001. These percentage changes are very 
similar to the percent change in average charges in DRGs 104 and 105 
after removing ICD and AICD charges, as described above. We note that 
the final relative weight values are based on 100 percent of FY 2000 
discharges in the MedPAR database as of March 2001. The analysis using 
average charges described above was based on an earlier sample of 
cases; therefore, the percentage changes do not match exactly.
    Comment: Other commenters noted that this change, and the resulting 
increase in payments for procedures remaining in DRGs 104 and 105, is a 
positive step to improving the payment for heart assist devices. 
However, the commenters were disappointed that we did not take the 
opportunity to make a similar revision for cases involving mechanical 
heart assist devices.
    Response: As described above, removing the ICDs/AICDs from DRGs 104 
and 105 will have the net effect of increasing the relative weights for 
both DRGs, so payment for the remaining cases will increase. We will 
continue to evaluate our options for improving the accuracy of our 
payments for heart assist technologies.
    After carefully reviewing all of the comments submitted, we have 
decided to proceed with the creation of two new DRGs to capture cases 
involving the implantation of cardiac defibrillators. The new DRGs 514 
and 515 include principal diagnosis codes and procedure codes as 
reflected in Chart 4 below:

                             Chart 4.--Composition of New DRGs 514 and 515 in MDC 5
----------------------------------------------------------------------------------------------------------------
                                                                                Included in DRG  Included in DRG
                         Diagnosis and procedure codes                                514              515
----------------------------------------------------------------------------------------------------------------
Principal Diagnosis Codes:
    All of the principal diagnosis codes assigned to MDC-5....................               X                X
Principal or Secondary Procedure Code:
    37.94  Implantation or replacement of automatic cardioverter/                            X                X
     defibrillator, total system (AICD).......................................
Combination Operating Procedure Codes:
    37.95  Implantation of automatic cardioverter/defibrillator lead(s) only;
        Plus
    37.96  Implantation of automatic cardioverter/defibrillator pulse                        X                X
     generator only;..........................................................
        Or
    37.97  Replacement of automatic cardioverter/defibrillator lead(s) only;
        Plus
    37.98  Replacement of automatic cardioverter/defibrillator pulse generator               X                X
     only.....................................................................
Plus: One of the Following Nonoperating Room ProcedureCodes:
    37.21  Right heart cardiac catheterization................................               X
    37.22  Left heart cardiac catheterization.................................               X

[[Page 39839]]

 
    37.23  Combined right and left heart cardiac catheterization..............               X
    37.26  Cardiac electrophysiologic stimulation and recording studies.......               X
    88.52  Angiocardiography of right heart structures........................               X
    88.53  Angiocardiography of left heart structures.........................               X
    88.54  Combined right and left heart angiocardiography....................               X
    88.55  Coronary arteriography using a single catheter.....................               X
    88.56  Coronary arteriography using two catheters.........................               X
    88.57  Other and unspecified coronary arteriography.......................               X
    88.58  Negative-contrast cardiac roentgenography..........................               X
----------------------------------------------------------------------------------------------------------------

b. Percutaneous Cardiovascular Procedures
    In the May 4 proposed rule, we indicated that we had reviewed other 
DRGs within MDC 5 in order to determine if there were also logic 
changes that could be made to these DRGs. The data were arrayed in a 
variety of ways displaying myriad permutations, resulting in the 
following proposed changes.
    A percutaneous transluminal coronary angioplasty (PTCA) is an acute 
intervention intended to minimize cardiac damage by restarting 
circulation to the heart. Some patients with an acute myocardial 
infarction (AMI) are now treated by performing a PTCA during the 
hospitalization for the AMI. Currently, PTCAs with a coronary stent 
implant are assigned to DRG 116 (Other Permanent Cardiac Pacemaker 
Implantation, or PTCA with Coronary Artery Stent Implant), along with 
pacemaker implants. The remaining percutaneous cardiovascular 
procedures are assigned to DRG 112 (Percutaneous Cardiovascular 
Procedures).
    The volume of percutaneous cardiovascular procedures has grown 
dramatically, with 186,669 cases identified in the FY 2000 MedPAR file 
containing hospital bills submitted through May 31, 2000. Because of 
the high volume, we decided to review the DRG for percutaneous 
cardiovascular procedures. As a first step in the evaluation, we 
combined the percutaneous cardiovascular procedures from DRGs 112 and 
116. We then subdivided the combined percutaneous cardiovascular 
procedure group into two groups based on the principal diagnosis (Pdx) 
of AMI.

------------------------------------------------------------------------
                                                                Average
                       Group                          Count      charge
------------------------------------------------------------------------
With Pdx of AMI...................................     50,442    $31,722
Without Pdx of AMI................................    136,227     23,989
------------------------------------------------------------------------

    Each of these groups was further evaluated by subdividing them 
based on whether a coronary stent was implanted. The vast majority of 
patients with an AMI had a coronary stent implanted. Patients without 
an AMI were subdivided into two groups based on whether a coronary 
stent was implemented.

------------------------------------------------------------------------
                                                                Average
                       Group                          Count      charge
------------------------------------------------------------------------
Without Pdx of AMI with stent.....................    111,441    $24,745
Without Pdx of AMI without stent..................     24,786     20,589
------------------------------------------------------------------------

    In the proposed rule, based on this analysis, we proposed the 
removal of PTCAs with coronary artery stent from DRG 116, thus limiting 
DRG 116 to permanent cardiac pacemaker implantation. This removal would 
leave approximately 68,000 non-PTCA cases in DRG 116.
    In conjunction with this evaluation, we considered a new 
technology, intravascular brachytherapy, that is being used to treat 
coronary in-stent stenosis. A gamma-radiation-impregnated tape is 
threaded through the affected vessel for a specified amount of dwell 
time, and then the tape is removed. Intravascular brachytherapy was 
approved by the Food and Drug Administration in November 2000.
    Intravascular brachytherapy is assigned to procedure code 92.27 
(Implantation or insert of radioactive elements). With the use of 
angioplasty, these cases are currently assigned to DRG 112 
(Percutaneous Cardiovascular Procedures). Therefore, cases involving 
this new technology will be implicated by these changes.
    Also in the proposed rule, we proposed to retitle DRG 116 ``Other 
Cardiac Pacemaker Implantation,'' remove DRG 112, and create three new 
DRGs: DRG 516 (Percutaneous Cardiovascular Procedures with Acute 
Myocardial Infarction (AMI)); DRG 517 (Percutaneous Cardiovascular 
Procedures without AMI, with Coronary Artery Stent Implant); and DRG 
518 (Percutaneous Cardiovascular Procedures without AMI, without 
Coronary Artery Stent Implant). In order to be assigned to new DRG 516, 
cases must contain one of the principal diagnoses plus the operating 
room procedures listed in Chart 5. Because DRG 516 contains acute 
myocardial infarction, which is hierarchically ordered before DRGs 517 
and 518, any AMI cases also containing codes 92.27 or 36.06 (Insertion 
of coronary artery stents(s)) would automatically be assigned to DRG 
516. We also proposed the assignment of patients with a percutaneous 
cardiovascular procedure and intravascular radiation treatment to new 
DRG 517. As more data become available, we will reassess the assignment 
of intravascular radiation treatment to DRG 517. New DRG 518 would 
contain the same operating room and nonoperating room procedures as new 
DRG 517, with the exception of codes 92.27 and 36.06. We received 10 
comments on this proposal.
    Comment: Several commenters supported the reclassification of 
percutaneous vascular procedures to DRGs within this MDC. Other 
commenters, however, stated the proposed changes would be inappropriate 
because they would reduce payment overall for percutaneous 
cardiovascular procedures. These commenters noted that new technologies 
associated with these procedures are, in fact, more costly rather than 
less costly. In addition, commenters expressed concern that payment for 
pacemakers under DRG 116 would be reduced from FY 2001 levels.
    Response: Based on 100 percent of FY 2000 discharges on file 
through March 2001, we estimate the case-weighted average relative 
weight for DRGs 116, 516, 517 and 518 to be 2.2236, a 4.5 percent 
decline from the case-weighted average relative weight for DRGs 112 and 
116 for FY 2001 (2.3280). As discussed above in relation to the new 
DRGs 514 and 515, the calculation of

[[Page 39840]]

the relative weights reflects the charges submitted by hospitals for 
these cases.
    Comment: Five commenters addressed only the inclusion of code 92.27 
(Implantation or insertion of radioactive elements, also known as 
brachytherapy) in new DRG 517 in cases without presence of AMI (these 
cases would go to DRG 516 if AMI were present). Four of the five 
expressed appreciation for this change, citing its clinical 
appropriateness and increased payment, which is close to the additional 
facility costs for performing the procedure.
    One commenter, while commending the decision to assign these cases 
to DRG 517, requested clarification about our decisionmaking process in 
assigning this technology to the same DRG as coronary stents. The 
commenter requested that we outline the specific criteria we applied or 
the process we followed to evaluate the adequacy of the external data 
submitted.
    Response: Although we received external data from a manufacturer of 
this technology, they were not the basis for our decision, as we were 
unable to verify the data because the data were submitted too late in 
the process of preparing the FY 2002 proposed rule. When we proposed to 
restructure DRGs 112 and 116, our decision was based on the clinical 
coherence of the DRGs. Intravascular radiation treatment is an invasive 
procedure that requires an additional 35 to 45 minutes, and requires 
the services of both a radiation (nuclear) physicist and a radiation 
safety officer in the operating room, as well as specifically trained 
operating room personnel, such as an ultrasound specialist.
    Comment: One commenter wrote that these changes fail to account for 
the use of GP IIB-IIIA inhibitors for cases with acute coronary 
syndromes. The commenter was concerned whether the DRG assignment for 
these cases under the proposed DRGs would be appropriate.
    Response: The administration of GP IIB-IIIA inhibitors is through 
intravenous infusion, and is assigned to code 99.20 (Injection or 
infusion of platelet inhibitor). The GROUPER does not recognize code 
99.20 as a procedure and, therefore, its presence does not affect DRG 
assignment. As described above, the DRG assignment for these cases 
under the newly configured DRGs 116, 516, 517, and 518 would be 
determined by the presence of AMI and the presence of other procedures 
that would cause the case to group to one of the other DRGs besides 
518. Our analysis of FY 2000 MedPAR data indicates that, among cases 
with code 99.20 currently assigned to either DRGs 112 or 116 for FY 
2000, the majority of these cases are currently assigned to DRG 116 
(317,108 discharges compared to 52,945). Therefore, the majority of 
these cases involve procedures that do affect DRG assignment. We will 
continue to evaluate these cases, however, to determine whether further 
revisions would be appropriate.
    Comment: One commenter indicated that codes 37.27 (Cardiac mapping) 
and 37.34 (Catheter ablation of lesion or tissues of heart) would now 
be grouped to new DRGs 516, 517, and 518. Because these procedures are 
not usually used on patients with AMI or patients who receive a stent, 
the commenter indicated the cases would most likely be grouped to DRG 
518. The commenter believed that we were unaware that certain 
procedures, such as the two previously mentioned, have greater resource 
utilization than other percutaneous cardiovascular procedures that do 
not involve AMI or stents. The commenter asserted that this is an 
inadvertently inappropriate classification. The commenter recommended 
that CMS either create a separate DRG for cardiac mapping and ablation 
procedures, or else assign codes 37.27 and 37.34 to DRG 516 after 
retitling the DRG appropriately.
    Response: These cases previously were assigned to either DRG 112 or 
116, depending upon whether they involved the insertion of a stent or 
the implantation of a pacemaker. This GROUPER assignment logic did not 
change, although the presence or absence of AMI is now a factor as 
well. We believe this is an appropriate clinical categorization. 
However, we will consider this issue as we continue to evaluate these 
DRGs.
    The principal diagnosis codes and operating room and nonoperating 
room procedure codes that are included in the new DRGs 516, 517, and 
518 are reflected in Chart 5.

                          Chart 5.--Composition of New DRGs 516, 517, and 518 in MDC 5
----------------------------------------------------------------------------------------------------------------
                                                                 Included in      Included in      Included in
                Diagnosis and procedure codes                      DRG 516          DRG 517          DRG 518
----------------------------------------------------------------------------------------------------------------
Principal Diagnosis Codes:
    410.01  Acute myocardial infarction of anterolateral                    X   ...............  ...............
     wall, initial episode of care...........................
    410.11  Acute myocardial infarction of other anterior                   X   ...............  ...............
     wall, initial episode of care...........................
    410.21  Acute myocardial infarction of inferolateral                    X   ...............  ...............
     wall, initial episode of care...........................
    410.31  Acute myocardial infarction of inferoposterior                  X   ...............  ...............
     wall, initial episode of care...........................
    410.41  Acute myocardial infarction of other inferior                   X   ...............  ...............
     wall, initial episode of care...........................
    410.51  Acute myocardial infarction of other lateral                    X   ...............  ...............
     wall, initial episode of care...........................
    410.61  True posterior wall infarction, initial episode                 X   ...............  ...............
     of care.................................................
    410.71  Subendocardial infarction, initial episode of                   X   ...............  ...............
     care....................................................
    410.81  Acute myocardial infarction of other specified                  X   ...............  ...............
     sites, initial episode of care..........................
    410.91  Acute myocardial infarction of unspecified site,                X   ...............  ...............
     initial episode of care.................................
Plus:
Operating Room Procedures:
     35.96  Percutaneous valvuloplasty.......................               X                X                X
        And
     36.01  Single vessel percutaneous transluminal coronary                X                X                X
     angioplasty (PTCA) or coronary atherectomy without
     mention of thrombolytic agent...........................
        Or
     36.02  Single vessel percutaneous transluminal coronary                X                X                X
     angioplasty (PTCA) or coronary atherectomy with mention
     of thrombolytic agent...................................
        Or
     36.05  Multiple vessel percutaneous transluminal                       X                X                X
     coronary angioplasty (PTCA) or coronary atherectomy
     performed during the same operation, with or without
     mention of thrombolytic agent...........................

[[Page 39841]]

 
        And
     36.09  Other removal of coronary artery obstruction.....               X                X                X
        And
     37.34  Catheter ablation of lesion or tissues of heart..               X                X                X
     92.27  Implantation or insertion of radioactive elements  ...............               X   ...............
Or:
Nonoperating Room Procedures:
     36.06  Insertion of coronary artery stent(s)............  ...............               X   ...............
     37.26  Cardiac electrophysiologic stimulation and                      X                X                X
     recording studies.......................................
     37.27  Cardiac mapping..................................               X                X                X
----------------------------------------------------------------------------------------------------------------

    DRG 121 (Circulatory Disorders with AMI and Major Complication, 
Discharged Alive), DRG 122 (Circulatory Disorders with AMI without 
Major Complication, Discharged Alive), and DRG 123 (Circulatory 
Disorders with AMI, Expired) are not affected by these changes.
c. Removal of Heart Assist Systems
    The ICD-9-CM Coordination and Maintenance Committee considered the 
nonoperative removal of heart assist systems at its November 17, 2000 
meeting. A device called the intra-aortic balloon pump (IABP) is one of 
the most common types of ventricular assist systems. A balloon catheter 
is placed into the patient's descending thoracic aorta, and inflates 
and deflates with each heartbeat. This device is timed with the 
patient's own heart rhythm, and inflates and circulates blood to the 
heart and other organs. This allows the heart to rest and recover. The 
IABP may be used preoperatively, intraoperatively, or postoperatively. 
It supports the patient from a few hours to several days.
    Code 37.64 (Removal of heart assist system) already exists, and it 
is considered by the GROUPER to be an operative procedure. However, the 
nonoperative removal of a heart assist system can be done at the 
patient's bedside, is noninvasive, and requires no anesthesia. 
Therefore, the Committee created code 97.44 (Nonoperative removal of 
heart assist system) for use with discharges beginning on or after 
October 1, 2001.
    In the past, we have assigned new ICD-9-CM codes to the same DRG to 
which the predecessor code was assigned. In the proposed rule, we 
explained that if this practice were to be followed, we would have 
proposed that code 97.44 be assigned to MDC 5, DRGs 478 (Other Vascular 
Procedures with CC) and 479 (Other Vascular Procedures without CC). 
After hospital charge data became available, we would have considered 
moving it to other DRGs. However, in accordance with section 533(a) of 
Public Law 106-554, which requires a more expeditious technique of 
recognizing new medical services or technology for the hospital 
inpatient prospective payment system, we will reconsider this 
longstanding practice when possible. Therefore, as code 97.44 was 
designed to capture heart assist system removal that is clearly 
nonoperative, we did not propose to designate 97.44 as a code which the 
GROUPER recognizes as a procedure. The GROUPER will assign these cases 
to a medical DRG based on the principal diagnosis, or to a surgical DRG 
if a surgical procedure recognized by the GROUPER is performed. This 
assignment can be found in Table 6B, New Procedure Codes, in the 
Addendum to this rule.
    We received no comments on this proposal. However, we did receive 
comments on another issue in MDC 5, relating to DRGs 110 and 111 (Major 
Cardiovascular Procedures with and without CC).
    Comment: One commenter submitted a case study on stent technology, 
noting that Medicare payments in their facility were 31.4 percent lower 
than total costs. This commenter made no recommendations, but stated 
that often surgeons must use additional stent segments to repair 
aneurysms, increasing total costs by thousands of dollars.
    Response: We do not have a clear understanding of the commenter's 
statement that often surgeons must use additional stent segments to 
repair aneurysms, thereby increasing total costs. We are unclear 
because the device presented to us for new ICD-9-CM code consideration 
was proposed as a single device, custom-fitted to the patient's needs. 
We will continue to monitor this technology and the new code (used for 
discharges on or after October 1, 2001).
    Comment: One commenter noted that aortic endografts are assigned to 
DRGs 110 and 111, and the cost of the device alone is greater than the 
entire payment for DRG 111. The commenter noted that this is a 
straightforward issue, and recommended that these cases be assigned 
specifically to DRG 110.
    Response: DRGs 110 and 111 are what we refer to as paired DRGs. 
Paired DRGs are exactly the same as each other with regard to the 
principal diagnosis and procedure codes in most cases. However, other 
aspects of the patient's case have a bearing on DRG assignment, such as 
the patient's age or the secondary diagnoses (which determine 
comorbidities or complications in appropriate DRGs). In this case, DRGs 
110 and 111 are divided based on the presence or absence of secondary 
diagnosis codes. If there are no secondary diagnosis codes present, the 
case will be assigned to DRG 111. It has been our experience that 
patients not having secondary diagnoses are less expensive for the 
hospital to treat, thereby resulting in a lower weighted DRG 
assignment.
    Hospitals should code their records completely, recording and 
submitting all relevant diagnosis and procedure codes having a bearing 
on the current admission. As noted previously, payment for each DRG is 
based on the average charges for cases assigned to that DRG as 
submitted to us by hospitals.
3. MDC 8 (Diseases and Disorders of the Musculoskeletal System and 
Connective Tissue)
a. Refusions
    We have received questions from correspondents regarding the 
appropriateness of the spinal fusion DRGs: DRG 496 (Combined Anterior/
Posterior Spinal Fusion); DRG 497 (Spinal Fusion with CC); and DRG 498 
(Spinal Fusion without CC). Several correspondents expressed concern 
about the inclusion of all refusions of the spine into one procedure 
code, 81.09 (Refusion of spine, any level or technique). The 
correspondents pointed out that because all refusions using any 
technique or level are in this one code,

[[Page 39842]]

all of these cases are assigned to DRG 497 and DRG 498. They also 
pointed out that fusion cases involving both an anterior and posterior 
technique are assigned to DRG 496. Although cases with the refusion 
code that involve anterior and posterior techniques would appear to be 
more appropriately assigned to DRG 496, this is not the case.
    We recognized this limitation in the refusion codes and further 
acknowledged that this limitation in the ICD-9-CM coding system creates 
DRG problems by preventing the assignment to DRG 496 even when both 
anterior and posterior techniques are used for refusion cases. 
Therefore, we referred the issue to the ICD-9-CM Coordination and 
Maintenance Committee and requested the Committee to consider code 
revisions for the refusions of the spine during its year 2000 public 
meetings.
    After its deliberations, the Committee approved a series of new 
procedure codes for refusion of the spine that could lead to 
improvements within DRGs 497 and 498. These new codes, listed below, go 
into effect on October 1, 2001.

81.30  Refusion of spine, not otherwise specified
81.31  Refusion of atlas-axis spine
81.32  Refusion of other cervical spine, anterior technique
81.33  Refusion of other cervical spine, posterior technique
81.34  Refusion of dorsal and dorsolumbar spine, anterior technique
81.35  Refusion of dorsal and dorsolumbar spine, posterior technique
81.36  Refusion of lumbar and lumbosacral spine, anterior technique
81.37  Refusion of lumbar and lumbosacral spine, lateral transverse 
process technique
81.38  Refusion of lumbar and lumbosacral spine, posterior technique
81.39  Refusion of spine, not elsewhere classified

    As previously stated, all refusions of the spine and corrections of 
the pseudarthrosis of the spine are assigned to code 81.09. Code 81.09, 
which is always assigned to DRG 497 or DRG 498, includes refusions at 
any level of the spine using any technique. With the creation of the 
new procedure codes listed above, it will be possible to determine the 
level of the spine at which the refusion is performed, as well as the 
technique used, and assign the case to a more appropriate DRG.
    These new procedure codes should greatly improve our ability to 
determine the level and technique used in the refusion.
    In the past, we have assigned new ICD-9-CM codes to the same DRG to 
which the predecessor code was assigned. In the proposed rule, we 
explained that if this practice were followed, these new codes would 
have been assigned to DRG 497 and 498 as they are currently. After data 
became available, we would have considered moving them to other DRGs. 
However, in accordance with section 533(a) of Public Law 106-554, which 
requires more expeditious methods of recognizing new medical services 
or technology under the inpatient hospital prospective payment system, 
we will reconsider this longstanding practice when possible. Since the 
new codes clearly allow us to identify cases where the technique was 
either anterior or posterior and these cases are clinically similar 
and, therefore, should be handled in the same fashion, we proposed to 
immediately assign these cases on the same basis as the fusion codes 
(81.00 through 81.09). We would not wait for actual claims data before 
making this change. These assignments are reflected in Chart 6 and also 
can be found in Table 6B, in section V. of the Addendum to this final 
rule.
    Comment: One commenter supported the creation of the ICD-9-CM codes 
for refusions as well as their proposed DRG assignments.
    Response: We appreciate the support of the commenter and are 
adopting the proposed DRG assignments for refusions of spine as final.
b. Fusion of Cervical Spine
    In the proposed rule we discussed an inquiry concerning the spinal 
DRGs that focused on fusions of the cervical spine. The inquirer stated 
that there was a significant difference between inpatients who undergo 
anterior cervical spinal fusion and other types of spinal fusion in 
regard to treatment, recovery time, costs, and risk of complications. 
Anterior cervical spinal fusions are assigned to procedure code 81.02 
(Other cervical fusion, anterior technique). The inquirer pointed out 
that anterior cervical fusions differ significantly from anterior 
techniques at other levels since the anatomic approach is far less 
invasive. Thoracic anterior techniques require working around the 
cardiac and respiratory systems in the chest cavity, while lumbar 
anterior techniques require working around bowel and digestive system 
and the abdominal muscles. The inquirer recommended that code 81.02 be 
removed from DRGs 497 and 498 and grouped separately.
    We analyzed claims data from the FY 2000 MedPAR file containing 
hospital bills received through May 31, 2000, and confirmed that 
charges are lower for fusions of the cervical spine than fusions of the 
thoracic and lumbar spine. This was true for both anterior and 
posterior cervical fusions of the spine. Our medical consultants agree 
that the data and their clinical analysis support the creation of new 
DRGs for cervical fusions of the spine. We proposed to remove procedure 
codes 81.02 and 81.03 from the spinal fusion DRGs (currently, DRGs 497 
and 498) and assign them to new DRGs for cervical spinal fusion with 
and without CC. We also proposed four groupings for fusion DRGs. The 
net effect of this change is an increase in the weights for DRGs 497 
and 498, since the lower charges for the cervical fusions would be 
removed. The average standardized charge for all spinal fusions with 
CCs was $26,957. For all spinal fusions without CCs, the average charge 
was $16,492. The table below also shows average standardized charges 
for these types of cases before and after the revisions.

------------------------------------------------------------------------
                                              Average     Average charge
       Revised spinal fusion DRGs          charge before       after
                                             revisions       revisions
------------------------------------------------------------------------
DRG 497 Spinal Fusion Except Cervical            $26,957         $36,821
 with CC................................
DRG 498 Spinal Fusion Except Cervical             17,492          26,297
 without CC.............................
DRG 519 Cervical Spinal Fusion with CC..  ..............          26,957
DRG 520 Cervical Spinal Fusion without    ..............          16,492
 CC.....................................
------------------------------------------------------------------------


[[Page 39843]]

    Based on the groupings, we proposed the creation of two new DRGs: 
DRG 519 (Cervical Spinal Fusion with CC); and DRG 520 (Cervical Spinal 
Fusion without CC). The procedure codes that would be included in the 
DRGs 519 and 520 are reflected in Chart 6 below.
    We also proposed to add the new ICD-9-CM procedure codes for 
refusion of the cervical spine (81.32 and 81.33) to the new cervical 
spine fusion DRGs because they are clinically similar.
    In addition, we proposed to retitle DRG 497 ``Spinal Fusion Except 
Cervical with CC'' and DRG 498 ``Spinal Fusion Except Cervical without 
CC.'' The retitled DRGs 497 and 498 would retain fusion codes 81.00, 
81.01, and 81.04 through 81.08 and include the new refusion codes 
81.30, 81.31, and 81.34 through 81.39, as reflected in Chart 6 below.
    Comment: One commenter commended the creation of the new ICD-9-CM 
codes for spinal refusions and the development of the new DRGs for 
cervical fusions. This commenter, a manufacturer of devices used for 
spinal fusions, agreed that cervical fusions on average cost less than 
lumbar and thoracic fusions. Another commenter who supported the 
creation of the new DRGs mentioned that this classification would more 
appropriately reflect the resources used in the varying cases.
    Two commenters asserted that DRGs 497 and 498 fail to take into 
account the cost variations when multi-level spinal fusions are 
performed. The commenters stated that the cost and complexity of a 
discharge varies substantially depending on the number of levels 
performed as part of a fusion procedure. Commenters recommended that 
new ICD-9-CM procedure codes be created for multi-level spine 
procedures to track and measure costs. The current ICD-9-CM codes do 
not differentiate between the number of levels that are fused. The 
commenter defined multi-level as three or more vertebral segments, 
either anterior or posterior, or both. In addition, the commenter 
recommended that these new multi-level fusion codes be assigned to the 
higher weighted DRG 496. The commenter recommended that DRG 496 be 
renamed ``Multi-Level Spine Procedure Anterior and/or Posterior for 
Stabilization and/or Correction and/or Refusion.''
    Response: We agree that the current ICD-9-CM procedure codes do not 
differentiate between the number of levels fused. This proposal will be 
addressed by the ICD-9-CM Coordination and Maintenance Committee at its 
November 1, 2001 meeting. A potential problem with this recommendation 
will be the need to avoid overlapping codes. The current fusion codes 
are based on an axis of the level of the fusion (cervical or lumbar) 
and an additional axis of the approach (anterior, posterior, or lateral 
transverse). Devising a modified or additional scheme that utilizes an 
additional axis of the number of disks fused may be quite challenging. 
If this scheme requires the use of a set of codes from the new Chapter 
17, we could quickly use up these currently empty codes. As far as the 
recommendation to include these new multi-level fusion codes in DRG 
496, this issue will be deferred until after the coding issue is 
addressed. If new codes are created, they will be included in an 
upcoming proposed rule along with their proposed DRG assignment.
    Since there was support for the proposed changes to the spinal 
DRGs, these will be implemented as final changes effective October 1, 
2001.
c. Posterior Spinal Fusion
    We received other correspondence regarding the current DRG 
assignment for code 81.07, Lumbar and lumbosacral fusion, lateral 
transverse process technique. The correspondent stated that physicians 
consider code 81.07 to be a posterior procedure. The patient is placed 
prone on the operating table and the spine is exposed through a 
vertical midline incision. The correspondent pointed out that code 
81.07 is not classified as a posterior procedure within DRG 496 
(Combined Anterior/Posterior Spinal Fusion). Therefore, when 81.07 is 
reported with one of the anterior techniques fusion codes, it is not 
assigned to DRG 496. The correspondent recommended that code 81.07 be 
added to the list of posterior spinal fusion codes for use in 
determining assignment to DRG 496.
    In the proposed rule, we indicated that we consulted with our 
clinical advisors and they agreed that this addition should be made. 
Since we proposed to handle the new refusion codes in the same manner 
as the fusion codes, we also proposed to assign DRG 496 when 81.37 is 
used with one of the anterior technique fusion or refusion codes. This 
would be similar to the manner in which code 81.07 is classified. For 
assignment to DRG 496, we would consider codes 81.02, 81.04, 81.06, 
81.32, 81.34, and 81.36 to be anterior techniques and codes 81.03, 
81.05, 81.07, 81.08, 81.33, 81.35, and 81.38 to be posterior 
techniques.

                           Chart 6.--Revised Composition of DRGS 496, 497, and 498 and Composition of DRG 519 and 520 in MDC 8
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                 Existing DRG 496
                                                         --------------------------------   Retained in     Retained in     Included in
              Diagnosis and procedure codes                 Assigned as     Assigned as     or Added to     or Added to       DRG 519
                                                             anterior        posterior     existing  DRG   existing  DRG    included in
                                                            techniques      techniques          497             498           DRG 520
-----------------------------------------------------------------------------------------------------------------------------------------
Principal or Secondary Procedure Codes:
    81.00  Spinal fusion, not otherwise specified.......  ..............  ..............              X               X   ..............  ..............
    81.01  Atlas-axis fusion............................  ..............  ..............              X               X   ..............  ..............
    81.02  Other cervical fusion, anterior technique....              X   ..............  ..............  ..............              X               X
    81.03  Other cervical fusion, posterior technique...  ..............              X   ..............  ..............              X               X
    81.04  Lumbar and lumbosacral fusion, anterior                    X   ..............              X               X   ..............  ..............
     technique..........................................
    81.05  Lumbar and lumbosacral fusion, posterior       ..............              X               X               X   ..............  ..............
     technique..........................................
    81.06  Lumbar and lumbosacral fusion, anterior                    X   ..............              X               X   ..............  ..............
     technique..........................................
    81.07  Lumbar and lumbosacral fusion, lateral         ..............              X               X               X   ..............  ..............
     transverse process technique.......................
    81.08  Lumbar and lumbosacral fusion, posterior       ..............              X               X               X   ..............  ..............
     technique..........................................

[[Page 39844]]

 
    81.30  Refusion of spine, not otherwise specified...  ..............  ..............              X               X   ..............  ..............
    81.31  Refusion of atlas-axis spine.................  ..............  ..............              X               X   ..............  ..............
    81.32  Refusion of other cervical spine, anterior                 X   ..............  ..............  ..............              X               X
     technique..........................................
    81.33  Refusion of other cervical spine, posterior    ..............              X   ..............  ..............              X               X
     technique..........................................
    81.34  Refusion of dorsal and dorsolumbar spine,                  X   ..............              X               X   ..............  ..............
     anterior technique.................................
    81.35  Refusion of dorsal and dorsolumbar spine,      ..............              X               X               X   ..............  ..............
     posterior technique................................
    81.36  Refusion of lumbar and lumbosacral spine,                  X   ..............              X               X   ..............  ..............
     anterior technique.................................
    81.37  Refusion of lumbar and lumbosacral spine,      ..............              X               X               X   ..............  ..............
     posterior technique................................
    81.38  Refusion of lumbar and lumbosacral spine,      ..............              X               X               X   ..............  ..............
     posterior technique................................
    81.39  Refusion of spine, not elsewhere classified..  ..............  ..............              X               X   ..............  ..............
--------------------------------------------------------------------------------------------------------------------------------------------------------

    There was no opposition expressed to the changes proposed for 
posterior spinal fusions; therefore, we are adopting the proposed 
changes as final.
d. Spinal Surgery
    The California Division of Workers' Compensation notified us of a 
possible problem with the following spinal DRGs:

DRG 496 (Combined Anterior/Posterior Spinal Fusion)
DRG 497 (Spinal Fusion with CC)
DRG 498 (Spinal Fusion without CC)
DRG 499 (Back & Neck Procedures except Spinal Fusion with CC)
DRG 500 (Back & Neck Procedures except Spinal Fusion without CC)

    The Division of Workers' Compensation uses the DRG categories 
developed by CMS to classify types of hospital care. However, instead 
of using CMS' weights for determining reimbursement for inpatient 
services, the Division sets a global fee for all inpatient medical 
services not otherwise exempted. This fee is established by multiplying 
the product of the DRG weight (or revised DRG weight for a small number 
of categories) and the health facility's composite factor by 1.20 to 
get the maximum amount for worker compensation admissions.
    The Division of Workers' Compensation has received reports that the 
formula it uses for reimbursing cases may be providing inadequate 
reimbursement. California hospitals and orthopedists have reported that 
certain spinal surgery DRGs (DRGs 496 through 500) may involve 
different types of care and/or technologies than those in use at the 
time these groups were formulated. Health care providers in California 
report ``recent increased use of the new implantation devices, 
hardware, and instrumentation, coupled with requirements for intensive 
hospital services accompanying use of new procedures, has led to 
inadequate reimbursement in these DRGs.'' As a short-term response to 
these concerns, the California Division of Workers' Compensation is 
exempting the costs of hardware and instrumentation from the global fee 
of the fee schedule for DRGs 496 through 500. The Division also 
requested that CMS examine these DRGs for any potential problem under 
the Medicare reimbursement system.
    The ICD-9-CM coding system does not capture specific types of 
implantation devices, hardware, and instrumentation. Therefore, we were 
not able to verify the claim that these new devices have led to 
increased costs in specific cases. We believe that the adoption of a 
more detailed coding system, such as ICD-10-PCS, would supply greater 
amounts of detail on these items. However, in the short term, it is not 
possible to identify a specific problem that involves implantation 
devices, hardware, and instrumentation.
    Comment: As previously stated, we received support for the proposed 
changes to the spinal fusion DRGs. As was also stated, one commenter 
pointed out that the current ICD-9-CM codes do not specify the number 
of levels fused, nor do they specify the types of devices used.
    One commenter, who manufactures spinal fusion devices, commended 
the new ICD-9-CM codes for refusions and the new DRGs for cervical 
fusions. This commenter also requested new codes specifying the number 
of levels fused. The commenter stated that typically two devices are 
used per level and therefore, with increased levels, there would be an 
increase in the number of infusion devices. The commenter recommended 
new codes for multi-level spinal fusions, but did not recommend new 
codes that would specify particular types of devices.
    Responses: This coding issue will be addressed at future meetings 
of the ICD-9-CM Coordination and Maintenance Committee. If new codes 
are created, their DRG assignment would be addressed in a subsequent 
proposed rule.
4. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract)
    We have received correspondence from a manufacturer of an 
implantable vascular device requesting that code 86.07 (Insertion of 
totally implantable vascular access device [VAD]) be assigned as an 
operative procedure in MDC 11, to DRG 315 (Other Kidney & Urinary Tract 
O.R. Procedures). This request was inadvertently omitted from the May 
4, 2001 proposed rule. Therefore, we are taking this opportunity to 
discuss possible designation of this procedure code as a code affecting 
DRG assignment in MDC 11.

[[Page 39845]]

    Procedure code 86.07 describes the implantation of a VAD into the 
chest wall and blood vessels of a patient's upper body. Patients 
requiring this particular device have been diagnosed with renal 
(kidney) failure. Insertion of a VAD allows access to the patient's 
blood for dialysis purposes when other sites for hemodialysis have been 
exhausted. According to representatives from the manufacturer of one 
particular VAD used for hemodialysis, this device costs the hospitals 
$1,750, and is usually inserted in the outpatient setting as opposed to 
admission for insertion of the device.
    The GROUPER program does not recognize code 86.07 as a procedure in 
other than MDC 9 (Disease and Disorders of the Skin, Subcutaneous 
Tissue and Breast), in DRGs 269 and 270 (Other Skin, Subcutaneous 
Tissue & Breast Procedure, with and without CC). Therefore, its 
presence in any other MDC does not affect DRG assignment. Patients who 
are admitted with renal failure and who have a VAD inserted will be 
assigned to DRG 316 (Renal Failure), absent any other surgical 
procedures. DRG 316 is a medical DRG with a lower relative weight than 
cases in the surgical DRGs within the same MDC.
    We extensively reviewed the MedPAR data. We found that code 86.07 
appeared in 358 different DRGs. Of these 358 DRGs, 173 include 
additional procedures recognized by GROUPER and are therefore 
considered surgical, while 185 are medical. Because of the space 
limitations of the ICD-9-CM, code 86.07 is used to describe VAD devices 
used for other purposes than hemodialysis.
    We looked specifically at the cases within DRGs 315 and 316 as 
shown in the two tables below:

                           DRG 315 (Surgical)
------------------------------------------------------------------------
                                                         Without  code
                                    With code 86.07          86.07
------------------------------------------------------------------------
Number of Cases.................  421................  19,815.
Average Length of Stay..........  12.5 days..........  6.8 days.
Average Charges.................  $39,946............  $23,061.
------------------------------------------------------------------------


                            DRG 316 (Medical)
------------------------------------------------------------------------
                                                          Without code
                                    With code 86.07          86.07
------------------------------------------------------------------------
Number of Cases.................  1,020..............  19,815.
Average Length of Stay..........  10.2 days..........  6.6 days.
Average Charges.................  $27,730............  $15,045.
------------------------------------------------------------------------

    Cases containing code 86.07 have higher average lengths of stay as 
well as higher average charges than cases not containing this code. We 
further examined the total number of reported procedures, as well as 
the range of average charges across both DRGs, for cases containing 
code 86.07. Both DRGs contain a significant number of additional 
procedures. The nature of these procedures varies widely, including 
such divergent procedures as X-rays and scans, injections, dental 
extraction, cardiac catheterization, aneurysm repair, and laparoscopic 
cholecystectomy. We also identified 24 cases in DRG 315 and 28 cases in 
DRG 316 with multiple insertions of the VAD. We believe those instances 
where the VAD is inserted as an inpatient procedure involve cases where 
other complications exist, leading to the higher average charges noted 
above. We are not assigning code 86.07 to DRG 315 as a surgical 
procedure, but will continue to consider possible alternative 
specifications of these DRGs.
    Additionally, we take this opportunity to clarify correct coding 
practice. It has come to our attention that a brochure is being 
distributed with the product that advocates coding insertion of the 
Lifesite Hemodialysis Access System using ICD-9-CM procedure 
code 86.07 in addition to code 39.93 (Insertion of vessel-to-vessel 
cannula). Inclusion of code 39.93 will force these cases into DRG 315, 
the higher weighted surgical DRG. Our data review showed 33 such cases 
of double coding. We would caution hospitals that the use of code 
39.93, in the absence of the actual procedure, is erroneous. According 
to our vascular surgeon consultant, the LifeSite Hemodialysis 
Access System as presented to us is not a vessel-to-vessel cannula. It 
is a device inserted into a vessel. Therefore, providers submitting 
code 39.93 without the actual procedure having been performed are at 
risk for review of fraudulent coding practice and DRG upcoding.
    This same product brochure contains the name and telephone number 
of a nationally recognized coding specialist. The addition of this 
specialist's name and number was included without her knowledge or 
consent. We take this opportunity to reiterate that LifeSite 
Hemodialysis Access System is correctly coded using 86.07 alone.
5. MDC 12 (Diseases and Disorders of the Male Reproductive System)
    At its May 11, 2000 public meeting, the ICD-9-CM Coordination and 
Maintenance Committee considered a request from a manufacturer to 
create a unique code for the procedure Penile plethysmography with 
nerve stimulation in DRG 334 (Major Male Pelvic Procedures with CC). 
The penile plethysmography is a test that can be performed during a 
radical prostatectomy procedure. During the course of the procedure, 
the physician places a probe within an area where the prostatic nerves 
are thought to be located and is able to detect minor changes in penile 
tumescence or detumescence. This reaction tells the physician that the 
nerve bundles have been located, which may aid the physician in 
performing a nerve-sparing radical prostatectomy procedure with 
precision. The nerve bundles can also be restimulated at the conclusion 
of the procedure, providing immediate feedback as to whether erectile 
function will be restored after surgery.
    After a presentation on the nerve identifying procedure and review 
of existing ICD-9-CM codes, the ICD-9-CM Coordination and Maintenance 
Committee determined that the existing

[[Page 39846]]

code 89.58 (Plethysmogram) adequately describes this test.
    Radical prostatectomies for patients with cancer of the prostate 
are grouped in either DRG 334 (Major Male Pelvic Procedures with CC) or 
DRG 335 (Major Male Pelvic Procedures without CC). We have received a 
request from a manufacturer of a nerve-identifying device to assign 
cases containing code 89.58 into DRG 334 only, not into DRG 335. DRG 
334 results in higher payments to hospitals. For FY 2002, DRG 334 has a 
relative weight of 1.5177, and DRG 335 has a relative weight of 1.1047. 
The manufacturer requested that we designate code 89.58 as an operating 
room procedure code that would be recognized by the GROUPER software, 
and make that code applicable only to DRG 334. The manufacturer 
believed that this would serve to take any cases of nerve sparing out 
of the lower paying DRG 335, and would make the technology more 
attractive to hospitals. As paired DRGs 334 and 335 are currently 
structured, they differ only in whether or not a secondary diagnosis 
identified as a CC is recorded.
    We examined those cases in DRG 334 to which the procedure code for 
prostatectomy was assigned. Of the total 7,241 cases in DRG 334 
identified, 5,611 of these cases contained procedure code 60.5 (Radical 
prostatectomy). Only three of the prostatectomy cases included code 
89.58. There are not a sufficient number of cases on which to base an 
assessment of the payment for this procedure. Therefore, we did not 
propose to modify the assignment of code 89.58.
    We received one comment on this proposal.
    Comment: The commenter argued that the analysis conducted on the 
procedure code assignment of 89.58 was incomplete, as it did not 
include evaluation of DRG 335 in the calculations. The commenter added 
that DRG also includes radical prostatectomies for patients with cancer 
of the prostate.
    Response: We apologize for the omission. Our review of data on DRG 
335 showed that the DRG contained 8,125 total cases. There were 8,117 
cases that did not contain procedure code 89.58; these cases had 
average total charges of $12,808. There were 8 cases in this group 
containing code 89.58. These 8 cases had average total charges of 
$16,366. We found a subset of 7,050 cases containing procedure code 
60.5; these cases had average total charges of $12,772. Within this 
subset, only 7 cases were reported containing codes 60.5 and 89.58. 
These 7 cases had average total charges of $16,593.
    Even including these additional cases, we identified very few cases 
in our analysis. Therefore, we are adopting as final our original 
proposed decision not to modify the assignment of code 89.58 by 
assigning it exclusively to DRG 334 within MDC 12. However, we will 
continue to monitor this procedure to determine whether a change in DRG 
assignment is warranted in the future.
6. MDC 15 (Newborns and Other Neonates With Conditions Originating in 
the Perinatal Period)
    DRG 390 (Neonate with Other Significant Problems) contains newborn 
or neonate cases with other significant problems not assigned to DRGs 
385 through 389, DRG 391, or DRG 469. To be assigned to DRG 389 (Full 
Term Neonate with Major Problems), the neonate must have one of the 
principal or secondary diagnosis listed under this DRG. A neonate is 
assigned to DRG 390 when the neonate has a principal or secondary 
diagnosis of newborn or neonate with other significant problems that 
are not assigned to DRG 385 through 389, 391, or 469.
    We have received correspondence suggesting a number of changes to 
be made to DRGs 398 and 391. These changes involve removing two codes 
from DRG 389 and adding 17 codes to DRG 391, as described below.
a. DRG 389 (Full Term Neonate with Major Problems)
    The correspondent suggested removing the following codes from DRG 
389 and assigning them to DRG 390:

773.0  Hemolytic disease due to RH isoimmunization
773.1  Hemolytic disease due to ABO isoimmunization

    The correspondent stated that hemolytic disease due to RH 
isoimmunization or due to ABO isoimmunization should not be considered 
a major problem. The correspondent recommended that these two 
conditions be classified as significant problems instead and thus 
assigned to DRG 390.
    Our medical consultants sought additional advice from the National 
Association of Children's Hospitals and Related Institutions (NACHRI). 
(CMS contracts with the 3M Health Information Systems to maintain the 
DRG system. The medical experts at 3M evaluate proposed DRG changes 
from a clinical perspective. These medical consultants assist CMS in 
evaluating alternative proposals.) NACHRI and our medical consultants 
agree that it is appropriate to remove codes 773.0 and 773.1 from DRG 
389. Therefore, we proposed to remove 773.0 and 773.1 from DRG 389 so 
that neonates with these conditions are assigned to DRG 390.
    Comment: Several commenters supported the proposed revisions for 
newborns within MDC 15. One commenter stated that the code assignments 
mentioned in the proposed rule are more appropriately classified based 
on their clinical attributes. Another commenter agreed with the 
proposed changes, but requested that an additional code be added to 
those being moved to DRG 391 (Normal Newborn). Specifically, the 
commenter requested that code 779.3, Feeding problems in newborns, be 
listed under DRG 391. Currently, when this code is listed as a 
secondary code, it results in the assignment of the neonate to DRG 390. 
The commenter stated that this condition and its resource consumption 
should not cause the neonate to be classified under DRG 390.
    Response: We discussed this additional issue with our medical 
consultants and they agreed that code 779.3 should also be listed under 
DRG 391. They concurred that the addition of this code as a secondary 
diagnosis should not lead to the newborn being classified as having a 
significant problem. Therefore, code 779.3 will be included among the 
codes being moved to DRG 391 as of October 1, 2001.
    Comment: One commenter suggested that codes 773.0 and 773.1 be 
removed from DRG 387 (Prematurity with major problems) in addition to 
DRG 389. The list of major problems in DRGs 389 and 387 mirror each 
other. The only difference is that DRG 387 includes premature newborns. 
The commenter asked us to consider codes 773.0 and 773.1 as significant 
problems for newborns and classify them into DRG 390, which would make 
them applicable for premature and full-term newborns.
    Response: We agree with the commenter. We are removing codes 773.0 
and 773.1 from DRG 389 as well as DRG 387. This removal will result in 
these cases being assigned to DRG 390 (Neonate with Other Significant 
Problems).
b. DRG 391 (Normal Newborn)
    We also have received correspondence with recommendations for 
changes to DRG 391. The correspondent pointed out that the following 
secondary codes currently lead to the assignment of the neonate to DRG 
390 (Neonate with Other Significant Problems). The correspondent 
believed that the conditions described by these codes

[[Page 39847]]

should not cause the neonate to be classified under DRG 390 when 
reported as a secondary diagnosis. The correspondent recommended that 
these conditions be listed under DRG 391 (Normal Newborn).

478.1  Other diseases of nasal cavity and sinuses
520.6  Disturbances in tooth eruption
623.8  Other specified noninflammatory disorders of vagina
709.00  Dyschromia, unspecified
709.01  Vitiglio
709.09  Dyschromia, Other
744.1  Accessory auricle
754.61  Congenital pes planus
757.33  Congenital pigmentary anomalies of skin
757.39  Other specified anomaly of skin
764.08  ``Light for dates'' without mention of fetal malnutrition, 
2,000-2,499 grams
764.98  Fetal growth retardation, unspecified, 2,000-2,499 grams
772.6  Cutaneous hemorrhage
794.15  Abnormal and auditory function studies
796.4  Other abnormal clinical findings
V20.2  Routine infant or child health check
V72.1  Examination of ears and hearing

    Our medical consultants also sought the advice of NACHRI on this 
recommendation. NACHRI reviewed the list of codes and agreed that none 
of these conditions should be considered to be a significant problem 
for a neonate. NACHRI concurred that neonates with these secondary 
diagnoses should be classified as normal newborns. Therefore, we 
proposed to add the codes listed above to DRG 391 and not classify them 
to DRG 390 when reported as a secondary diagnosis.
    Comment: One commenter expressed concern that the weights assigned 
to five newborn DRGs (DRGs 385, 368, 387, 388, and 389) are 
undervalued. The commenter pointed out that legislation mandating Early 
Hearing Detection and Intervention (EHDI) has been passed in 35 States 
plus the District of Columbia. In these States, hearing screening must 
be performed prior to the newborn's discharge from the hospital unless 
prevented by medical complications. The cost per screening ranges from 
$15 to $30, which includes personnel, supplies, and equipment costs 
which are amortized over 3 years. The screening also includes costs for 
babies that require diagnostic evaluation.
    The commenter requested that data from States that have not 
implemented EHDI programs be deleted from the Medicare supplemental 
database for, at a minimum, DRG 391 (Normal Newborn). The commenter 
stated that non-Medicare data used for developing the weights for the 
five newborn DRGs do not represent average costs if some of the 19 
States that supply supplemental non-Medicare data are States that 
perform hearing screenings on less than 90 percent of newborns. The 
commenter further requested that we use data only from States that have 
EHDI programs that are operational at the 90 percent level. The 
commenter provided a list of States that meet these criteria.
    Response: While we appreciate the commenter's furnishing us with 
information on the costs of providing services such as hearing 
screenings, it would be inappropriate for us to use this one service to 
determine whether or not to include a State's data because the State 
does not provide the service at a 90-percent level. The DRG weights are 
based on averages. As hospitals elect to include or exclude services, 
the weights will change over time. Therefore, we are not developing a 
criterion to exclude hospital data from States that do not have a 90-
percent compliance level with EHDI.
    Comment: One commenter noted that new procedure code 75.38, Fetal 
pulse osimetry, was classified as a nonoperative procedure code in 
Table 6B of the Addendum of the proposed rule. As a nonoperative 
procedure, it was not assigned to an MDC or to specific DRGs. The 
commenter requested that we assign code 75.38 to MDC 14 (Pregnancy, 
Childbirth and Puerperium), and the following DRGs:

DRG 370--(Caesarean Section with CC)
DRG 371--(Caesarean Section without CC)
DRG 372--(Vaginal Delivery with Complicating Diagnosis)
DRG 373--(Vaginal Delivery without CC)

    The commenter believed it was critical that the clinical benefits 
and use of fetal pulse oximetry be closely tracked in order to monitor 
clinical outcomes and to recognize potential economic advantages. The 
commenter acknowledged that most labor and delivery patients are not 
Medicare beneficiaries. However, other third party payers benchmark 
hospital inpatient payment rates from Medicare DRGs. The commenter 
stated that if code 75.38 does not contribute or link to a DRG, it is 
often simply not coded. The commenter further stated that fetal 
oximetry is an exciting and significant emerging technology and that 
much knowledge can be gained by understanding its usage in the context 
of labor and delivery services.
    Response: The commenter requested that 75.38 be assigned to the 
DRGs for deliveries (DRG 370 through 373). However, these DRGs are 
currently assigned based on the procedure codes for the specific type 
of delivery (caesarian or vaginal). Adding the procedure code 75.38 to 
these delivery DRGs would not affect the DRG assignment. The cases 
would still be assigned to the appropriate DRG based on the type of 
delivery, not whether the baby received fetal pulse oximetry. If the 
commenter is suggesting that the fetal pulse oximetry code, on its own, 
should lead to the DRG assignment, this option is not workable. Without 
knowing that the mother actually delivered, and the type of delivery, 
one would not be able to assign the case to one of the delivery DRGs. 
Once one knew through the procedure codes that the mother delivered, 
and the type of delivery, the addition of 75.38 would not add to the 
DRG assignment.
    The commenter did not make an argument as to why 75.38 was 
incorrectly classified as a nonoperating room procedure. While we 
appreciate the commenter's desire that this new procedure code be used, 
assigning the code to existing DRGs is not consistent with the 
structure of DRGs. Procedure codes are only assigned to DRGs when they 
effect the DRG assignment logic. Therefore, we are not changing the 
operating room status of code 75.38, nor are we adding it to the 
delivery DRGs. Code 75.38 will be considered a nonoperative procedure.
c. Medicare Code Editor Changes
    The Medicare Code Editor (MCE) is a front-end software program that 
detects and reports errors in the coding of claims data. The age 
conflict edit detects inconsistencies between a patient's age and any 
diagnosis on the patient's record. A subset of diagnoses is considered 
valid only for patients over the age of 14 years. These diagnoses are 
identified as ``adult'' diagnoses and range in age from 15 through 124 
years. Therefore, any codes included on the Newborn Diagnoses edit are 
valid only for patients under age 14.
    It has come to our attention that cases including the ICD-9-CM code 
770.7, Chronic respiratory disease arising in the perinatal period, are 
being rejected. However, a condition such as bronchopulmonary dysplasia 
always originates in the perinatal period, so regardless of the 
patient's age, this condition is always coded as 770.7. The age at 
which the diagnosis was established or the age at continuing treatment 
does not affect the assignment of code 770.7.

[[Page 39848]]

    Because correct coding is causing these claims to be rejected, in 
the May 4 proposed rule we proposed to remove code 770.7 from the 
Newborn Diagnoses edit in the MCE, as well as remove it from DRG 387 
(Prematurity with Major Problems) and DRG 389 (Full Term Neonate with 
Major Problems). Clinical conditions in code 770.7, such as pulmonary 
fibrosis, would group to DRG 92 (Interstitial Lung Disease with CC) and 
DRG 93 (Interstitial Lung Disease without CC). Therefore, we proposed 
the addition of code 770.7 to DRGs 92 and 93, as they are most similar 
clinically. We indicated that we would monitor these cases in upcoming 
MedPAR data to ascertain that the cases consume similar resources.
    We received no comments on these proposals, and are, therefore, 
adopting the change as final.
7. MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental 
Disorders)
    DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other 
Symptomatic Treatment with CC) is assigned when the patient has a 
principal diagnosis of alcohol or drug abuse or dependence along with a 
secondary diagnosis classified as a CC. If these patients do not have a 
CC, they are assigned to DRG 435 (Alcohol/Drug Abuse or Dependency, 
detoxification or Other Symptomatic Treatment without CC). When the 
patients receive rehabilitation and detoxification therapy during the 
stay, they are assigned to DRG 437 (Alcohol/Drug Dependence, Combined 
Rehabilitation and Detoxification Therapy). If the patients receive 
only rehabilitation therapy, they are assigned to DRG 436 (Alcohol/Drug 
Dependence with Rehabilitation Therapy).
    We have received inquiries as to why the relative weight for DRG 
437, which includes both rehabilitation and detoxification (for FY 
2001, the relative weight is .6606, with a geometric mean length of 
stay of 7.5) is lower than the FY 2001 relative weight for DRG 434, 
which includes only detoxification (.7256, with a geometric mean length 
of stay of 3.9). Likewise, the FY 2001 relative weight for DRG 436, 
which includes only rehabilitation (.7433), is higher than the FY 2001 
relative weight for DRG 437, which includes combined rehabilitation and 
detoxification therapy (.6606). The inquirers indicated that those 
patients receiving the combination therapy would be expected to have a 
longer length of stay, require more services, and, therefore, be more 
costly to treat.
    We analyzed data from the FY 2000 MedPAR file and did not find 
support for the inquirers' assertion that combination therapy is more 
costly to treat. The relative weights indicate that the presence of a 
CC in DRG 434 leads to a significantly higher weight than is found in 
DRG 435, which does not have a CC. Therefore, we analyzed the alcohol/
drug DRGs and focused on eliminating the distinction between 
rehabilitation and rehabilitation with detoxification and assessing the 
impact of CCs. We combined data on DRGs 436 and 437 and then subdivided 
the data based on the presence or absence of a CC. The following table 
contains the results of the analysis.

                                 Average Charges for Cases--With and Without CCs
----------------------------------------------------------------------------------------------------------------
                                                            With CC                         Without CC
                                               -----------------------------------------------------------------
                     DRGS                                             Length of                        Length of
                                                  Count      Charge      stay      Count      Charge      stay
----------------------------------------------------------------------------------------------------------------
Detoxification Cases--DRG 434 and DRG 435.....      3,298     $8,548        5.0      9,689     $5,111        4.1
All Rehabilitation Cases--DRG 436 and DRG 437.      3,298      8,117       10.1      4,473      7,407        9.6
----------------------------------------------------------------------------------------------------------------

    We found that, for both the detoxification and rehabilitation DRGs, 
the with-CC group has higher charges than the without-CC group. 
However, the with-CC groups still contain the anomaly that the 
detoxification DRG 434 has a slightly higher average charge than the 
combined rehabilitation DRGs 436 and 437. It appears that any 
significant medical problems as indicated by the presence of a CC 
dominate the cost incurred by hospitals for treating alcohol and drug 
abuse patients. For the without-CC groups, the detoxification DRG 435 
has substantially lower average charges than the combined 
rehabilitation DRGs 436 and 437. Because the average charges of the 
with-CC for both the detoxification DRG 434 and combined rehabilitation 
DRGs 436 and 437 have similar average charges, we proposed to combine 
these two groups.
    Based on the results of our analysis, we proposed to restructure 
MDC 20 as follows. We first identified those cases with a principal 
diagnosis within MDC 20 where the patient left against medical advice. 
These cases are found in DRG 433 (Alcohol/Drug Abuse or Dependence, 
Left Against Medical Advice (AMA)). We next identified all remaining 
cases with a principal diagnosis within MDC 20 where there was a CC. We 
assigned these cases to a new DRG, (Alcohol/Drug Abuse or Dependence 
with CC). The remaining cases (without CC and did not leave against 
medical advice) were then divided into two new DRGs based on whether or 
not the patient received rehabilitation (Alcohol/Drug Abuse or 
Dependence without CC, with Rehabilitation Therapy; and Alcohol/Drug 
Abuse or Dependence without CC, without Rehabilitation Therapy).
    The following table illustrates the number of patients and average 
charges for each of the four proposed DRGs.

              Frequencies and Average Charges for New DRGs
------------------------------------------------------------------------
                                                 Number  of    Average
         DRG                 Group title           cases       charges
------------------------------------------------------------------------
433.................  Alcohol/Drug Abuse or           3,509       $3,855
                       Dependence, Left
                       Against Medical Advice.
521.................  Alcohol/Drug Abuse or          18,235        8,470
                       Dependence with CC.
522.................  Alcohol/Drug Abuse or           4,473        7,407
                       Dependence without CC,
                       with Rehabilitation
                       Therapy.
523.................  Alcohol/Drug Abuse or           9,689        5,111
                       Dependence without CC,
                       without Rehabilitation
                       Therapy.
------------------------------------------------------------------------


[[Page 39849]]

    This table illustrates that groups based first on the presence of 
CC and then on whether or not the patient receives rehabilitation 
therapy provide a much better explanation of differences in charges. 
Therefore, we proposed to retain DRG 433, make DRGs 434 through 437 
invalid, and create new DRGs 521, 522, and 523 to include the diagnosis 
and procedure codes reflected in Chart 7 below.

      Chart 7.--Restructure of MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders)
----------------------------------------------------------------------------------------------------------------
                                                Included in
        Diagnosis and procedure code            Existing DRG   Included in DRG  Included in DRG  Included in DRG
                                                    433              521              522              523
----------------------------------------------------------------------------------------------------------------
Principal diagnosis:
    All principal diagnosis within existing                X   ...............  ...............  ...............
     MDC 20 involving cases in which
     patients left against medical advice
     (AMA)..................................
    All principal diagnoses within existing   ...............               X   ...............  ...............
     MDC 20 where there is a CC and where
     patient did not leave against medical
     advice (AMA)...........................
    All principal diagnoses within existing
     MDC 20 without CC and where patient did
     not leave against medical advice (AMA).
    All principal diagnoses in existing MDC   ...............  ...............  ...............               X
     20 without CC involving cases where
     patients did not leave against medical
     advice (AMA)...........................
Procedure Codes:
    94.61  Alcohol rehabilitation...........  ...............  ...............               X   ...............
    94.63  Alcohol rehabilitation and         ...............  ...............               X   ...............
     detoxification.........................
    94.64  Drug rehabilitation..............  ...............  ...............               X   ...............
    94.66  Drug rehabilitation and            ...............  ...............               X   ...............
     detoxification.........................
    94.67  Combined alcohol and drug          ...............  ...............               X   ...............
     rehabilitation.........................
    94.69  Combined alcohol and drug          ...............  ...............               X   ...............
     rehabilitation and detoxification......
----------------------------------------------------------------------------------------------------------------

    Comment: One commenter was uncertain as to the intent of the 
reclassification of the DRGs to identify alcohol/drug use and alcohol/
drug-induced organic mental disorders. The commenter expressed concern 
that the cases associated with alcohol/drug use would have a lower 
overall weight relative to the overall average weight of these cases in 
FY 2001. The commenter requested further information on the impact of 
this change in the final rule. Additionally, the commenter recommended 
that the title for DRG 521 be changed from ``Alcohol/Drug Abuse or 
Dependence with CC'' to ``Alcohol/Drug Abuse with CC, with or without 
Rehabilitation Therapy.''
    Response: As described above, for FY 2001, cases receiving combined 
rehabilitation and detoxification (DRG 437) had a lower relative weight 
than patients receiving only detoxification (DRG 434) or rehabilitation 
(DRG 436). Since these relative weights are derived from actual claims 
data, we decided to review the issue to determine if other factors had 
any impact. It would be expected that those patients receiving the 
combination therapy would have a longer length of stay, require more 
services, and therefore be more costly to treat. This was not supported 
by the data.
    The factor that seems to contribute the greatest to the costs of 
these cases is the presence of a CC. The presence of a CC had a greater 
impact on the average charges than did factors such as detoxification 
or rehabilitation. Once the importance of this factor was determined, 
the cases not leaving against medical advice (DRG 433) were split on 
whether or not a CC was present. Those with a CC were assigned to new 
DRG 521. The remaining cases were then split based on whether or not 
rehabilitation was provided.
    As can be seen from the FY 2002 relative weights in the chart 
below, MDC 20 patients who have a CC are considerably more expensive to 
treat. They have the highest relative weight among this set of DRGs. 
The second highest weight is assigned to MDC 20 cases without CC who 
also received rehabilitation services.

------------------------------------------------------------------------
                                                 Number of      Final
                   DRG title                      of cases     weights
------------------------------------------------------------------------
DRG 433 Alcohol/Drug Abuse or Dependence, Left        5,522        .2888
 AMA..........................................
DRG 521 Alcohol/Drug Abuse or Dependence with        28,014        .7355
 CC...........................................
DRG 522 Alcohol/Drug Abuse or Dependence              6,852        .6249
 without CC, with Rehabilitation Therapy......
DRG 523 Alcohol/Drug Abuse or Dependence             14,954        .3997
 without CC, without Rehabilitation Therapy...
------------------------------------------------------------------------

    As can be seen from this chart, the majority of patients are 
assigned to DRG 521, which has the highest relative weight among the 
MDC 20 DRGs. As is the case for all DRGs, the relative weights reflect 
hospitals' actual charges submitted for bills in the FY 2000 MedPAR 
file. Data support the new splits based first on the presence of a CC 
and then on the presence of rehabilitation therapy. Therefore, we are 
adopting the proposed DRG classification changes as final without 
change.
    While we appreciate the comment on modifying the title for DRG 521, 
we believe that it does not add to the clarity of the DRG. All MDC 20 
patients who have not left AMA but who have a CC are assigned to DRG 
521. The presence or absence of a code for rehabilitation therapy does 
not effect the DRG assignment for these cases. Therefore, we are 
adopting the proposed title as final without change.
8. MDC 25 (Human Immunodeficiency Virus Infections)
    Effective October 1, 2000, ICD-9-CM diagnosis codes 783.2 (Abnormal 
loss of weight) and 783.4 (Lack of expected normal physiological 
development) were made invalid (65 FR 47171). These

[[Page 39850]]

two old diagnosis codes were expanded to five digits and the following 
new diagnosis codes were created:

783.21 Loss of weight
783.22 Underweight
783.40 Unspecified lack of normal physiological development
783.41 Failure to thrive
783.42 Delayed milestones
783.43 Short stature

    These six revised codes were created in response to an industry 
request. Specifically, code 783.2 did not differentiate between whether 
the patient had lost weight recently or whether the patient was 
underweight. Code 783.4 was expanded to capture concepts such as 
failure to thrive, delayed milestones, and short stature. None of these 
concepts were captured in the old codes.
    We listed these new codes in the August 1, 2000 final rule on the 
hospital inpatient prospective payment system in Table 6A--New 
Diagnosis Codes (65 FR 47169). At the time the final rule was 
published, all of these codes were assigned to DRGs 296 through 298. 
After the final rule was published, we received an inquiry as to why 
these new diagnosis codes were not included in MDC 25 as human 
immunodeficiency virus (HIV)-related conditions. The inquirer pointed 
out that the predecessor codes (783.2 and 783.4) were included in MDC 
25 as HIV-related conditions and suggested that the new codes be added 
to MDC 25. These cases will be assigned to other MDCs if the patient 
does not have HIV.
    In the proposed rule, we stated that we agreed that the expanded 
codes should have been placed in the MDC 25 as HIV-related conditions. 
The omission was an oversight. Therefore, we proposed to add diagnosis 
codes 783.21, 783.22, 783.40, 783.41, 783.42, and 783.43 as HIV-related 
conditions within MDC 25. When these six revised codes are reported 
with code 042 HIV, the patient will be classified within MDC 25.
    Comment: One commenter supported the placement of codes 783.21, 
783.22, 783.40, 783.41, 783.42, and 783.43, as HIV-related conditions 
within MDC 25.
    Response: We appreciate the commenter's support and are adopting 
the proposed changes as final.
9. Surgical Hierarchies
    Some inpatient stays entail multiple surgical procedures, each one 
of which, occurring by itself, could result in assignment of the case 
to a different DRG within the MDC to which the principal diagnosis is 
assigned. Therefore, it is necessary to have a decision rule by which 
these cases are assigned to a single DRG. The surgical hierarchy, an 
ordering of surgical classes from most resource intensive to least, 
performs that function. Its application ensures that cases involving 
multiple surgical procedures are assigned to the DRG associated with 
the most resource-intensive surgical class.
    Because the relative resource intensity of surgical classes can 
shift as a function of DRG reclassification and recalibration, we 
reviewed the surgical hierarchy of each MDC, as we have for previous 
reclassifications, to determine if the ordering of classes coincided 
with the intensity of resource utilization, as measured by the same 
billing data used to compute the DRG relative weights.
    A surgical class can be composed of one or more DRGs. For example, 
in MDC 11, the surgical class ``kidney transplant'' consists of a 
single DRG (DRG 302) and the class ``kidney, ureter and major bladder 
procedures'' consists of three DRGs (DRGs 303, 304, and 305). 
Consequently, in many cases, the surgical hierarchy has an impact on 
more than one DRG. The methodology for determining the most resource-
intensive surgical class involves weighting each DRG for frequency to 
determine the average resources for each surgical class. For example, 
assume surgical class A includes DRGs 1 and 2 and surgical class B 
includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 
is higher than that of DRG 3, but the average charges of DRGs 4 and 5 
are higher than the average charge of DRG 2. To determine whether 
surgical class A should be higher or lower than surgical class B in the 
surgical hierarchy, we would weight the average charge of each DRG by 
frequency (that is, by the number of cases in the DRG) to determine 
average resource consumption for the surgical class. The surgical 
classes would then be ordered from the class with the highest average 
resource utilization to that with the lowest, with the exception of 
``other OR procedures'' as discussed below.
    This methodology may occasionally result in a case involving 
multiple procedures being assigned to the lower-weighted DRG (in the 
highest, most resource-intensive surgical class) of the available 
alternatives. However, given that the logic underlying the surgical 
hierarchy provides that the GROUPER searches for the procedure in the 
most resource-intensive surgical class, this result is unavoidable.
    We note that, notwithstanding the foregoing discussion, there are a 
few instances when a surgical class with a lower average relative 
weight is ordered above a surgical class with a higher average relative 
weight. For example, the ``other OR procedures'' surgical class is 
uniformly ordered last in the surgical hierarchy of each MDC in which 
it occurs, regardless of the fact that the relative weight for the DRG 
or DRGs in that surgical class may be higher than that for other 
surgical classes in the MDC. The ``other OR procedures'' class is a 
group of procedures that are least likely to be related to the 
diagnoses in the MDC but are occasionally performed on patients with 
these diagnoses. Therefore, these procedures should only be considered 
if no other procedure more closely related to the diagnoses in the MDC 
has been performed.
    A second example occurs when the difference between the average 
weights for two surgical classes is very small. We have found that 
small differences generally do not warrant reordering of the hierarchy 
since, by virtue of the hierarchy change, the relative weights are 
likely to shift such that the higher-ordered surgical class has a lower 
average weight than the class ordered below it.
    Based on the preliminary recalibration of the DRGs, we proposed the 
modification of the surgical hierarchy as set forth below. As we stated 
in the September 1, 1989 final rule (54 FR 36457), we are unable to 
test the effects of proposed revisions to the surgical hierarchy and to 
reflect these changes in the proposed relative weights due to the 
unavailability of the revised GROUPER software at the time the proposed 
rule is prepared. Rather, we simulate most major classification changes 
to approximate the placement of cases under the proposed 
reclassification and then determine the average charge for each DRG. 
These average charges then serve as our best estimate of relative 
resource use for each surgical class. We test the proposed surgical 
hierarchy changes after the revised GROUPER is received and reflect the 
final changes in the DRG relative weights in the final rule. Further, 
as discussed in section II.C. of this preamble, we anticipate that the 
final recalibrated weights will be somewhat different from those 
proposed, because they will be based on more complete data. 
Consequently, in the proposed rule we stated that further revision of 
the hierarchy, using the above principles, might be necessary in the 
final rule.
    In the May 4 proposed rule, we proposed to revise the surgical 
hierarchy for the pre-MDC DRGs, MDC 5 (Diseases and Disorders of the 
Circulatory System), MDC 8 (Diseases

[[Page 39851]]

and Disorders of the Musculoskeletal System & Connective Tissue) and 
MDC 20 (Alcohol/Drug Use & Alcohol/Drug Induced-Organic Mental 
Disorders) as follows:
     In the pre-MDC DRGs, we proposed to reorder Lung 
Transplant (DRG 495) above Bone Marrow Transplant (DRG 481). We also 
proposed to reorder Simultaneous Pancreas/Kidney Transplant (DRG 512) 
and Pancreas Transplant (DRG 513) above Lung Transplant (DRG 495).
     In MDC 5, we proposed to reorder Cardiac Defibrillator 
Implants (DRGs 514 and 515) above Other Cardiothoracic Procedures (DRG 
108). We also proposed to reorder Percutaneous Cardiovascular 
Procedures (DRGs 516, 517, and 518) above Other Vascular Procedures 
(DRGs 478 and 479).
     In MDC 8, we proposed to reorder Cervical Spinal Fusion 
(DRGs 519 and 520) above Back & Neck Procedures Except Spinal Fusion 
(DRGs 499 and 500).
     In MDC 20, we proposed to order as follows: Alcohol/Drug 
Abuse or Dependence, Left AMA (DRG 433) above Alcohol/Drug Abuse or 
Dependence With CC (DRG 521); Alcohol/Drug Abuse or Dependence With CC 
(DRG 521) above Alcohol/Drug Abuse or Dependence With Rehabilitation 
Therapy Without CC (DRG 522); and Alcohol/Drug Abuse or Dependence With 
Rehabilitation Therapy Without CC (DRG 522) above Alcohol/Drug Abuse or 
Dependence Without Rehabilitation Therapy Without CC (DRG 523).
    Comment: One commenter expressed support for hierarchy proposals.
    Response: We appreciate the commenter's support. Based on a test of 
the proposed revisions using the March 2001 update of the FY 2000 
MedPAR file and the revised GROUPER software, we have found that the 
revisions are still supported by the data, and no additional changes 
are indicated. Therefore, we are adopting these proposed changes as 
final.
10. Refinement of Complications and Comorbidities (CC) List
    In the September 1, 1987 final notice (52 FR 33143) concerning 
changes to the DRG classification system, we modified the GROUPER logic 
so that certain diagnoses included on the standard list of CCs would 
not be considered a valid CC in combination with a particular principal 
diagnosis. Thus, we created the CC Exclusions List. We made these 
changes for the following reasons: (1) to preclude coding of CCs for 
closely related conditions; (2) to preclude duplicative coding or 
inconsistent coding from being treated as CCs; and (3) to ensure that 
cases are appropriately classified between the complicated and 
uncomplicated DRGs in a pair. We developed this standard list of 
diagnoses using physician panels to include those diagnoses that, when 
present as a secondary condition, would be considered a substantial 
complication or comorbidity. In previous years, we have made changes to 
the standard list of CCs, either by adding new CCs or deleting CCs 
already on the list. We stated in the proposed rule that we did not 
propose to delete any of the diagnosis codes on the CC list at that 
time.
    In the May 19, 1987 proposed notice (52 FR 18877) concerning 
changes to the DRG classification system, we explained that the 
excluded secondary diagnoses were established using the following five 
principles:
     Chronic and acute manifestations of the same condition 
should not be considered CCs for one another (as subsequently corrected 
in the September 1, 1987 final notice (52 FR 33154)).
     Specific and nonspecific (that is, not otherwise specified 
(NOS)) diagnosis codes for a condition should not be considered CCs for 
one another.
     Conditions that may not coexist, such as partial/total, 
unilateral/bilateral, obstructed/unobstructed, and benign/malignant, 
should not be considered CCs for one another.
     The same condition in anatomically proximal sites should 
not be considered CCs for one another.
     Closely related conditions should not be considered CCs 
for one another.
    The creation of the CC Exclusions List was a major project 
involving hundreds of codes. The FY 1988 revisions were intended only 
as a first step toward refinement of the CC list in that the criteria 
used for eliminating certain diagnoses from consideration as CCs were 
intended to identify only the most obvious diagnoses that should not be 
considered complications or comorbidities of another diagnosis. For 
that reason, and in light of comments and questions on the CC list, we 
have continued to review the remaining CCs to identify additional 
exclusions and to remove diagnoses from the master list that have been 
shown not to meet the definition of a CC. (See the September 30, 1988 
final rule (53 FR 38485) for the revision made for the discharges 
occurring in FY 1989; the September 1, 1989 final rule (54 FR 36552) 
for the FY 1990 revision; the September 4, 1990 final rule (55 FR 
36126) for the FY 1991 revision; the August 30, 1991 final rule (56 FR 
43209) for the FY 1992 revision; the September 1, 1992 final rule (57 
FR 39753) for the FY 1993 revision; the September 1, 1993 final rule 
(58 FR 46278) for the FY 1994 revisions; the September 1, 1994 final 
rule (59 FR 45334) for the FY 1995 revisions; the September 1, 1995 
final rule (60 FR 45782) for the FY 1996 revisions; the August 30, 1996 
final rule (61 FR 46171) for the FY 1997 revisions; the August 29, 1997 
final rule (62 FR 45966) for the FY 1998 revisions; the July 31, 1998 
final rule (63 FR 40954) for the FY 1999 revisions, and the August 1, 
2000 final rule (65 FR 47064) for the FY 2001 revisions.) In the July 
30, 1999 final rule (64 FR 41490) we did not modify the CC Exclusions 
List for FY 2000 because we did not make any changes to the ICD-9-CM 
codes for FY 2000.
    In this final rule, we are making a limited revision of the CC 
Exclusions List to take into account the changes that will be made in 
the ICD-9-CM diagnosis coding system effective October 1, 2001. (See 
section II.B.11. below, for a discussion of ICD-9-CM changes.) These 
changes are being made in accordance with the principles established 
when we created the CC Exclusions List in 1987.
    Tables 6F and 6G in section V. of the Addendum to this final rule 
contain the revisions to the CC Exclusions List that will be effective 
for discharges occurring on or after October 1, 2001. Each table shows 
the principal diagnoses with changes to the excluded CCs. Each of these 
principal diagnoses is shown with an asterisk, and the additions or 
deletions to the CC Exclusions List are provided in an indented column 
immediately following the affected principal diagnosis.
    CCs that are added to the list are in Table 6G--Additions to the CC 
Exclusions List. Beginning with discharges on or after October 1, 2001, 
the indented diagnoses will not be recognized by the GROUPER as valid 
CCs for the asterisked principal diagnosis.
    CCs that are deleted from the list are in Table 6H--Deletions from 
the CC Exclusions List. Beginning with discharges on or after October 
1, 2001, the indented diagnoses will be recognized by the GROUPER as 
valid CCs for the asterisked principal diagnosis.
    Copies of the original CC Exclusions List applicable to FY 1988 can 
be obtained from the National Technical Information Service (NTIS) of 
the Department of Commerce. It is available in hard copy for $133.00 
plus shipping and handling. A request for the FY 1988 CC Exclusions 
List (which should

[[Page 39852]]

include the identification accession number (PB) 88-133970) should be 
made to the following address: National Technical Information Service, 
United States Department of Commerce, 5285 Port Royal Road, 
Springfield, VA 22161; or by calling (800) 553-6847.
    Users should be aware of the fact that all revisions to the CC 
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 
1997, 1998, and 1999) and those in Tables 6F and 6G of this document 
must be incorporated into the list purchased from NTIS in order to 
obtain the CC Exclusions List applicable for discharges occurring on or 
after October 1, 2001. (Note: There was no CC Exclusions List in FY 
2000 because we did not make changes to the ICD-9-CM codes for FY 
2000.)
    Alternatively, the complete documentation of the GROUPER logic, 
including the current CC Exclusions List, is available from 3M/Health 
Information Systems (HIS), which, under contract with CMS, is 
responsible for updating and maintaining the GROUPER program. The 
current DRG Definitions Manual, Version 18.0, is available for $225.00, 
which includes $15.00 for shipping and handling. Version 19.0 of this 
manual, which includes the final FY 2002 DRG changes, will be available 
in October 2001 for $225.00. These manuals may be obtained by writing 
3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 
06492; or by calling (203) 949-0303. Please specify the revision or 
revisions requested.
11. Review of Procedure Codes in DRGs 468, 476, and 477
    Each year, we review cases assigned to DRG 468 (Extensive OR 
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR 
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive 
OR Procedure Unrelated to Principal Diagnosis) to determine whether it 
would be appropriate to change the procedures assigned among these 
DRGs.
    DRGs 468, 476, and 477 are reserved for those cases in which none 
of the OR procedures performed are related to the principal diagnosis. 
These DRGs are intended to capture atypical cases, that is, those cases 
not occurring with sufficient frequency to represent a distinct, 
recognizable clinical group. DRG 476 is assigned to those discharges in 
which one or more of the following prostatic procedures are performed 
and are unrelated to the principal diagnosis:

60.0  Incision of prostate
60.12  Open biopsy of prostate
60.15  Biopsy of periprostatic tissue
60.18  Other diagnostic procedures on prostate and periprostatic tissue
60.21  Transurethral prostatectomy
60.29  Other transurethral prostatectomy
60.61  Local excision of lesion of prostate
60.69  Prostatectomy NEC
60.81  Incision of periprostatic tissue
60.82  Excision of periprostatic tissue
60.93  Repair of prostate
60.94  Control of (postoperative) hemorrhage of prostate
60.95  Transurethral balloon dilation of the prostatic urethra
60.99  Other operations on prostate

    All remaining OR procedures are assigned to DRGs 468 and 477, with 
DRG 477 assigned to those discharges in which the only procedures 
performed are nonextensive procedures that are unrelated to the 
principal diagnosis. The original list of the ICD-9-CM procedure codes 
for the procedures we consider nonextensive procedures, if performed 
with an unrelated principal diagnosis, was published in Table 6C in 
section IV. of the Addendum to the September 30, 1988 final rule (53 FR 
38591). As part of the final rules published on September 4, 1990 (55 
FR 36135), August 30, 1991 (56 FR 43212), September 1, 1992 (57 FR 
23625), September 1, 1993 (58 FR 46279), September 1, 1994 (59 FR 
45336), September 1, 1995 (60 FR 45783), August 30, 1996 (61 FR 46173), 
and August 29, 1997 (62 FR 45981), we moved several other procedures 
from DRG 468 to 477, and some procedures from DRG 477 to 468. No 
procedures were moved in FY 1999, as noted in the July 31, 1998 final 
rule (63 FR 40962); in FY 2000, as noted in the July 30, 1999 final 
rule (64 FR 41496); or in FY 2001, as noted in the August 1, 2000 final 
rule (65 FR 47064).
a. Moving Procedure Codes From DRGs 468 or 477 to MDCs
    We annually conduct a review of procedures producing assignment to 
DRG 468 or DRG 477 on the basis of volume, by procedure, to see if it 
would be appropriate to move procedure codes out of these DRGs into one 
of the surgical DRGs for the MDC into which the principal diagnosis 
falls. The data are arrayed two ways for comparison purposes. We look 
at a frequency count of each major operative procedure code. We also 
compare procedures across MDCs by volume of procedure codes within each 
MDC.
    Our medical consultants identified those procedures occurring in 
conjunction with certain principal diagnoses with sufficient frequency 
to justify adding them to one of the surgical DRGs for the MDC in which 
the diagnosis falls. Based on this year's review, we did not identify 
any necessary changes in procedures under DRG 477 and, therefore, we 
did not propose to move any procedures from DRG 477 to one of the 
surgical DRGs. However, our medical consultants have identified a 
number of procedure codes that should be removed from DRG 468 and put 
into more clinically coherent DRGs. The movements of these codes are 
specified in the charts below:

                                    Movement of Procedure Codes From DRG 468
----------------------------------------------------------------------------------------------------------------
                                                                 Included  in
       Procedure code                    Description                  DRG                  Description
----------------------------------------------------------------------------------------------------------------
                               MDC 1--Diseases and Disorders of the Nervous System
----------------------------------------------------------------------------------------------------------------
5495........................  Peritoneal Incision.............               7  Peripheral and Cranial Nerve and
                                                                                 Other Nervous System Procedures
                                                                                 with CC.
5495........................  Peritoneal Incision.............               8  Peripheral and Cranial Nerve and
                                                                                 Other Nervous System Procedures
                                                                                 without CC.
----------------------------------------------------------------------------------------------------------------
                                    MDC 3--Diseases and Disorders of the Ear
----------------------------------------------------------------------------------------------------------------
3821........................  Blood Vessel Biopsy.............              63  Other Ear, Nose, Mouth and
                                                                                 Throat OR Procedure.
----------------------------------------------------------------------------------------------------------------
                             MDC 4--Diseases and Disorders of the Respiratory System
----------------------------------------------------------------------------------------------------------------
3821........................  Blood Vessel Biopsy.............              76  Other Respiratory System OR
                                                                                 Procedures with CC.

[[Page 39853]]

 
3821........................  Blood Vessel Biopsy.............              77  Other Respiratory System OR
                                                                                 Procedures with CC.
3929........................  Vascular Shunt & Bypass NEC.....              76  Other Respiratory System OR
                                                                                 Procedures with CC.
3929........................  Vascular Shunt & Bypass NEC.....              77  Other Respiratory System OR
                                                                                 Procedures with CC.
3931........................  Suture of Artery................              76  Other Respiratory System OR
                                                                                 Procedures with CC.
3931........................  Suture of Artery................              77  Other Respiratory System OR
                                                                                 Procedures with CC.
5411........................  Exploratory Laparotomy..........              76  Other Respiratory System OR
                                                                                 Procedures with CC.
5411........................  Exploratory Laparotomy..........              77  Other Respiratory System OR
                                                                                 Procedures with CC.
7749........................  Bone Biopsy NEC.................              76  Other Respiratory System OR
                                                                                 Procedures with CC.
7749........................  Bone Biopsy NEC.................              77  Other Respiratory System OR
                                                                                 Procedures with CC.
8669........................  Free Skin Graft NEC.............              76  Other Respiratory System OR
                                                                                 Procedures with CC.
8669........................  Free Skin Graft NEC.............              77  Other Respiratory System OR
                                                                                 Procedures with CC.
----------------------------------------------------------------------------------------------------------------
                             MDC 5--Diseases and Disorders of the Circulatory System
----------------------------------------------------------------------------------------------------------------
3402........................  Exploratory Thoracotomy.........             120  Other Circulatory System OR
                                                                                 Procedures.
3403........................  Reopen Thoractomy Site..........             120  Other Circulatory System OR
                                                                                 Procedures.
3421........................  Transpleura Thoracoscopy........             120  Other Circulatory System OR
                                                                                 Procedures.
3422........................  Mediastinoscopy.................             120  Other Circulatory System OR
                                                                                 Procedures.
3426........................  Open Mediastinal Biopsy.........             120  Other Circulatory System OR
                                                                                 Procedures.
436.........................  Distal Gastrectomy..............             120  Other Circulatory System OR
                                                                                 Procedures.
437.........................  Partial Gastrectomy with Jejunal             120  Other Circulatory System OR
                               Anastomosis.                                      Procedures.
4389........................  Partial Gastrectomy.............             120  Other Circulatory System OR
                                                                                 Procedures.
4399........................  Total Gastrectomy...............             120  Other Circulatory System OR
                                                                                 Procedures.
4561........................  Multiple Segment Small Bowel                 120  Other Circulatory System OR
                               Excision.                                         Procedures.
4562........................  Partial Small Bowel Resection                120  Other Circulatory System OR
                               NEC.                                              Procedures.
4572........................  Cecectomy.......................             120  Other Circulatory System OR
                                                                                 Procedures.
4573........................  Right Hemicolectomy.............             120  Other Circulatory System OR
                                                                                 Procedures.
4574........................  Transverse Colon Resection......             120  Other Circulatory System OR
                                                                                 Procedures.
4575........................  Left Hemicolectomy..............             120  Other Circulatory System OR
                                                                                 Procedures.
4579........................  Partial Large Bowel Excision NEC             120  Other Circulatory System OR
                                                                                 Procedures.
458.........................  Total Intra-Abdominal Colectomy.             120  Other Circulatory System OR
                                                                                 Procedures.
4593........................  Small-to-Large Bowel NEC........             120  Other Circulatory System OR
                                                                                 Procedures.
4603........................  Large Bowel Exteriorization.....             120  Other Circulatory System OR
                                                                                 Procedures.
4613........................  Permanent Colostomy.............             120  Other Circulatory System OR
                                                                                 Procedures.
4709........................  Other Appendectomy..............             120  Other Circulatory System OR
                                                                                 Procedures.
4862........................  Anterior Rectal Resection With               120  Other Circulatory System OR
                               Colostomy.                                        Procedures.
4863........................  Anterior Rectal Resection NEC...             120  Other Circulatory System OR
                                                                                 Procedures.
4869........................  Rectal Resection................             120  Other Circulatory System OR
                                                                                 Procedures.
5012........................  Open Liver Biopsy...............             120  Other Circulatory System OR
                                                                                 Procedures.
540.........................  Abdominal Wall Incision.........             120  Other Circulatory System OR
                                                                                 Procedures.
----------------------------------------------------------------------------------------------------------------
                              MDC 6--Diseases and Disorders of the Digestive System
----------------------------------------------------------------------------------------------------------------
5122........................  Cholecystectomy.................             170  Other Digestive System OR
                                                                                 Procedures with CC.
5122........................  Cholecystectomy.................             171  Other Digestive System OR
                                                                                 Procedures without CC.
5123........................  Laparoscopic Cholecystectomy....             170  Other Digestive System OR
                                                                                 Procedures with CC.
5132........................  GB-To-Intestine Anastomosis.....             170  Other Digestive System OR
                                                                                 Procedures with CC.
5136........................  Choledochoenterostomy...........             170  Other Digestive System OR
                                                                                 Procedures with CC.
5136........................  Choledochoenterostomy...........             171  Other Digestive System OR
                                                                                 Procedures without CC.
5137........................  Hepatic Duct-GI Anastomosis.....             170  Other Digestive System OR
                                                                                 Procedures with CC.
5137........................  Hepatic Duct-GI Anastomosis.....             171  Other Digestive System OR
                                                                                 Procedures without CC.
5159........................  Bile Duct Incision NEC..........             170  Other Digestive System OR
                                                                                 Procedures with CC.
5159........................  Bile Duct Incision NEC..........             171  Other Digestive System OR
                                                                                 Procedures without CC.
----------------------------------------------------------------------------------------------------------------
                     MDC 7--Diseases and Disorders of the Hepatobiliary System and Pancreas
----------------------------------------------------------------------------------------------------------------
540.........................  Abdominal Wall Incision.........             201  Other Heptobiliary and Pancreas
                                                                                 Procedure.
----------------------------------------------------------------------------------------------------------------
                MDC 8--Diseases and Disorders of the Musculoskeletal System and Connective Tissue
----------------------------------------------------------------------------------------------------------------
3479........................  Other Chest Wall Repair.........             233  Other Musculoskeletal System &
                                                                                 Connective Tissue OR Procedure
                                                                                 with CC.
3479........................  Other Chest Wall Repair.........             234  Other Musculoskeletal System &
                                                                                 Connective Tissue OR Procedure
                                                                                 with CC.
----------------------------------------------------------------------------------------------------------------
                         MDC 11--Diseases and Disorders of the Kideny and Urinary Tract
----------------------------------------------------------------------------------------------------------------
540.........................  Abdominal Wall Incision.........             315  Other Kidney & Urinary Tract OR
                                                                                 Procedure.
5451........................  Laparoscopic Periton                         315  Other Kidney & Urinary Tract OR
                               Adhesiolysis.                                     Procedure.
5459........................  Other Periton Adhesiolysis......             315  Other Kidney & Urinary Tract OR
                                                                                 Procedure.
----------------------------------------------------------------------------------------------------------------


[[Page 39854]]

b. Reassignment of Procedures among DRGs 468, 476, and 477
    We also annually review the list of ICD-9-CM procedures that, when 
in combination with their principal diagnosis code, result in 
assignment to DRGs 468, 476, and 477, to ascertain if any of those 
procedures should be moved from one of these DRGs to another of these 
DRGs based on average charges and length of stay. We look at the data 
for trends such as shifts in treatment practice or reporting practice 
that would make the resulting DRG assignment illogical. If our medical 
consultants were to find these shifts, we would propose moving cases to 
keep the DRGs clinically similar or to provide payment for the cases in 
a similar manner. Generally, we move only those procedures for which we 
have an adequate number of discharges to analyze the data. Based on our 
review this year, we did not propose to move any procedures from DRG 
468 to DRGs 476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG 
477 to DRGs 468 or 476.
c. Adding Diagnosis Codes to MDCs
    Based on our review this year, we did not propose to add any 
diagnosis codes to MDCs.
    We received one comment in support of the proposed changes to the 
procedure codes in DRG 468, 476, and 477. In this final rule, we are 
adopting these proposed changes without further modification.
12. Changes to the ICD-9-CM Coding System
    As described in section II.B.1. of this preamble, the ICD-9-CM is a 
coding system that is used for the reporting of diagnoses and 
procedures performed on a patient. In September 1985, the ICD-9-CM 
Coordination and Maintenance Committee was formed. This is a Federal 
interdepartmental committee, co-chaired by the National Center for 
Health Statistics (NCHS) and CMS, charged with maintaining and updating 
the ICD-9-CM system. The Committee is jointly responsible for approving 
coding changes, and developing errata, addenda, and other modifications 
to the ICD-9-CM to reflect newly developed procedures and technologies 
and newly identified diseases. The Committee is also responsible for 
promoting the use of Federal and non-Federal educational programs and 
other communication techniques with a view toward standardizing coding 
applications and upgrading the quality of the classification system.
    The NCHS has lead responsibility for the ICD-9-CM diagnosis codes 
included in the Tabular List and Alphabetic Index for Diseases, while 
CMS has lead responsibility for the ICD-9-CM procedure codes included 
in the Tabular List and Alphabetic Index for Procedures.
    The Committee encourages participation in the above process by 
health-related organizations. In this regard, the Committee holds 
public meetings for discussion of educational issues and proposed 
coding changes. These meetings provide an opportunity for 
representatives of recognized organizations in the coding field, such 
as the American Health Information Management Association (AHIMA) 
(formerly American Medical Record Association (AMRA)), the American 
Hospital Association (AHA), and various physician specialty groups as 
well as physicians, medical record administrators, health information 
management professionals, and other members of the public to contribute 
ideas on coding matters. After considering the opinions expressed at 
the public meetings and in writing, the Committee formulates 
recommendations, which then must be approved by the agencies.
    The Committee presented proposals for coding changes for 
implementation in FY 2002 at public meetings held on May 11, 2000 and 
November 17, 2000, and finalized the coding changes after consideration 
of comments received at the meetings and in writing by January 08, 
2001.
    Copies of the Coordination and Maintenance Committee minutes of the 
2000 meetings can be obtained from the CMS home page at: http://www.hcfa.gov/medicare/icd9cm.htm. Paper copies of these minutes are no 
longer available and the mailing list has been discontinued. We 
encourage commenters to address suggestions on coding issues involving 
diagnosis codes to: Donna Pickett, Co-Chairperson; ICD-9-CM 
Coordination and Maintenance Committee; NCHS; Room 1100; 6525 Belcrest 
Road; Hyattsville, MD 20782. Comments may be sent by E-mail to: 
[email protected].
    Questions and comments concerning the procedure codes should be 
addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination 
and Maintenance Committee; CMS, Center for Medicare Management, 
Purchasing Policy Group, Division of Acute Care; C4-07-07; 7500 
Security Boulevard; Baltimore, MD 21244-1850. Comments may be sent by 
E-mail to: [email protected].
    The ICD-9-CM code changes that have been approved will become 
effective October 1, 2001. The new ICD-9-CM codes are listed, along 
with their DRG classifications, in Tables 6A and 6B (New Diagnosis 
Codes and New Procedure Codes, respectively) in section V. of the 
Addendum to this final rule. As we stated above, the code numbers and 
their titles were presented for public comment at the ICD-9-CM 
Coordination and Maintenance Committee meetings. Both oral and written 
comments were considered before the codes were approved. In the 
proposed rule, we solicited comments only on the proposed DRG 
classification of these new codes.
    Further, the Committee has approved the expansion of certain ICD-9-
CM codes to require an additional digit for valid code assignment. 
Diagnosis codes that have been replaced by expanded codes or other 
codes or have been deleted are in Table 6C (Invalid Diagnosis Codes). 
These invalid diagnosis codes will not be recognized by the GROUPER 
beginning with discharges occurring on or after October 1, 2001. For 
codes that have been replaced by new or expanded codes, the 
corresponding new or expanded diagnosis codes are included in Table 6A 
(New Diagnosis Codes). New procedure codes are shown in Table 6B. Table 
6C contains invalid diagnosis codes, and Table 6D contains invalid 
procedure codes. Revisions to diagnosis code titles are in Table 6E 
(Revised Diagnosis Code Titles), which also include the DRG assignments 
for these revised codes. Revisions to procedure code titles are in 
Table 6F (Revised Procedure Codes Titles).
    In September 2000, the Department implemented a policy of paying 
for inpatient hospital stays for Medicare beneficiaries participating 
in clinical trials (HCFA Program Memorandum AB 00-89, September 19, 
2000). Hospitals were encouraged to identify the patients involved by 
reporting an ICD-9-CM code. This would allow the examination of data on 
the patients involved in clinical trials. However, there was no clear 
ICD-9-CM diagnosis code for patients who took part in a clinical trial. 
There was a code for patients receiving an examination as part of the 
control group for clinical trials. This control group code was V70.7 
(Examination for normal comparison or control in clinical research). 
Hospitals were instructed to use V70.5 (Health examination of defined 
subpopulations), for patients participating in a clinical trial.
    This coding directive has created some confusion because of the 
title and description of the two codes. Hospitals also have requested 
that all clinical patients be captured under one code. They indicated 
that the use of one code

[[Page 39855]]

would be especially useful because patients frequently do not know if 
they are part of the control group or are receiving new therapy.
    To help alleviate the confusion, the ICD-9-CM Coordination and 
Maintenance Committee revised code V70.7. Effective October 1, 2001, 
the new title of code V70.7 is ``Examination of patient in clinical 
trial.'' This revision will make it easier to capture data on Medicare 
beneficiaries who are participating in a clinical trial.
    Comment: One commenter questioned the DRG assignment of 525.12 
(Loss of teeth due to periodontal disease) listed in Table 6A of the 
Addendum of the proposed rule. Table 6A in the proposed rule listed the 
proposed DRG assignments within MDC 3 for this new code as DRGs 182, 
183, and 184. The commenter stated that the DRG assignments within MDC 
3 should actually be DRGs 185, 186, and 187, since these were the DRGs 
used for its predecessor code, 525.1. The commenter also pointed out 
that the other new codes within this category (525.10-525.19) were 
assigned to DRGs 185, 186, and 187.
    Response: The commenter is correct. We are assigning code 525.12 to 
DRGs 185, 186, and 187 within MDC 3. This is consistent with the way 
the other codes in the new category were assigned. In this final rule, 
we are correcting Table 6A to show that 525.12 is assigned to DRGs 185, 
186, and 187 within MDC 3.
13. Other Issues
a. Pancreas Transplant
    Effective July 1, 1999, Medicare covers whole organ pancreas 
transplantation if the transplantation is performed simultaneously with 
or after a kidney transplant (procedure codes 55.69 (Other kidney 
transplantation), or diagnosis code V42.0 (Organ or tissue replaced by 
transplant, Kidney), along with 52.80 (Pancreatic transplant, not 
otherwise specified), or 52.82 (Homotransplant of pancreas)). A 
discussion of the history of these coverage decisions and codes can be 
found in the August 1, 2000 final rule on the prospective payment 
system for FY 2001 (65 FR 47067).
    We discussed the appropriate DRG classification for these cases in 
both the July 30, 1999 final rule (64 FR 41497) and the August 1, 2000 
final rule (65 FR 47067). Currently, cases can be assigned to one of 
two major DRGs depending on principal diagnosis. If a kidney transplant 
and a pancreas transplant are performed simultaneously on a patient 
with chronic renal failure secondary to diabetes with renal 
manifestations (diagnosis codes 250.40 through 250.43), the cases will 
be assigned to DRG 302 (Kidney Transplant). If a pancreas transplant is 
performed following a kidney transplant (during a different hospital 
admission) on a patient with chronic renal failure secondary to 
diabetes with renal manifestations, the case is assigned to DRG 468 
(Extensive OR Procedure Unrelated to Principal Diagnosis). This is 
because pancreas transplant is not assigned to MDC 11 (Diseases and 
Disorders of the Kidney and Urinary Tract), the MDC to which a 
principal diagnosis of chronic renal failure secondary to diabetes is 
assigned.
    In the August 1, 2000 final rule, we noted that we would continue 
to monitor these transplant cases to determine the appropriateness of 
establishing a new DRG. For the May 4 proposed rule, using data in the 
FY 2000 MedPAR file (updated through May 31, 2000), we analyzed the 
cases for which procedure codes 52.80 and 52.82 were reported. (Our 
data showed that 15 of the cases were coded using 52.83 
(Heterotransplant of pancreas), which is not a covered procedure under 
any circumstances.) We identified a total of 221 cases for this time 
period. The United Network for Organ Sharing (UNOS) reported it had 
identified 270 cases through September 2000.
    These 221 MedPAR cases were distributed over 6 DRGs, with the 
majority (158 cases or 72 percent) assigned to DRG 302, and 23 cases 
(10 percent) assigned to DRG 468. The remaining 40 cases were 
distributed between 4 other DRGs, with the majority (25 cases) being 
assigned to DRG 292 (Other Endocrine, Nutritional and Metabolic OR 
Procedures with CC). Four cases were assigned to DRG 483 (Tracheostomy 
with Principal Diagnosis except Face, Mouth and Neck Diagnoses) in the 
Pre-MDC grouping, which took precedence over any other DRG assignment.
    We arrayed the data based on the presence or absence of kidney 
transplant; that is, pancreas transplant codes with or without 55.69. 
The majority of cases (166 or 75 percent) had the combined kidney-
pancreas transplant in one operative episode, with 55 (25 percent) of 
the cases having pancreas transplant subsequent to the kidney 
transplant. Differences in hospital charges were significantly higher 
for a pancreas transplant plus a kidney transplant ($138,809) than a 
pancreas transplant alone ($85,972), and both were higher than average 
standardized charges in DRG 302 ($64,760) or DRG 468 ($39,707), 
although it must be noted that these figures do reflect the resource 
intensive patients assigned to DRG 483. Those patients in DRG 483 had 
average standardized charges of $377,934.
    Because these categories of patients do not fit into existing DRGs 
from either a clinical or resource perspective, in the May 4 proposed 
rule, we proposed to create two new DRGs that would reflect these 
patients' unique clinical profiles: DRG 512 (Simultaneous Pancreas/
Kidney Transplant) and DRG 513 (Pancreas Transplants). Cases grouped to 
either DRGs 512 or 513 must have a principal or secondary diagnosis 
code and procedure code or combination of procedure codes as indicated 
in the chart below:

                                    Composition of Proposed DRGs 512 and 513
----------------------------------------------------------------------------------------------------------------
                                                                                  Included in      Included in
                         Diagnosis and procedure codes                              DRG 512          DRG 513
----------------------------------------------------------------------------------------------------------------
Principal or Secondary ICD-9-CM Diabetes Mellitus Code:
    250.00  Diabetes mellitus without mention of complication, Type II or                    X                X
     unspecified type, not as stated as uncontrolled..........................
    250.01  Diabetes mellitus without mention of complication, Type I, not                   X                X
     stated as uncontrolled...................................................
    250.02  Diabetes mellitus without mention of complication, Type II or                    X                X
     unspecified type, uncontrolled...........................................
    250.03  Diabetes mellitus without mention of complication, Type I,                       X                X
     uncontrolled.............................................................
    250.10  Diabetes with ketoacidosis, Type II or Unspecified type, not                     X                X
     stated as uncontrolled...................................................
    250.11  Diabetes with ketoacidosis, Type I, not stated as uncontrolled....               X                X
    250.12  Diabetes with ketoacidosis, Type II or unspecified type,                         X                X
     uncontrolled.............................................................
    250.13  Diabetes with ketoacidosis, Type I, controlled....................               X                X
    250.20  Diabetes with hyperosmolarity, Type II or unspecified type, not                  X                X
     stated as uncontrolled...................................................
    250.21  Diabetes with hyperosmolarity, Type I, not stated as uncontrolled.               X                X

[[Page 39856]]

 
    250.22  Diabetes with hyperosmolarity, Type II or unspecified type,                      X                X
     uncontrolled.............................................................
    250.23  Diabetes with hyperosmolarity, Type I, uncontrolled...............               X                X
    250.30  Diabetes with other coma, Type II or unspecified type, not stated                X                X
     as uncontrolled..........................................................
    250.31  Diabetes with other coma, Type I, not stated as uncontrolled......               X                X
    250.32  Diabetes with other coma, Type II or unspecified type,                           X                X
     uncontrolled.............................................................
    250.33  Diabetes with other coma, Type I, uncontrolled....................               X                X
    250.40  Diabetes with renal manifestations, Type II or unspecified type,                 X                X
     not stated as uncontrolled...............................................
    250.41  Diabetes with renal manifestations, Type I, not stated as                        X                X
     uncontrolled.............................................................
    250.42  Diabetes with renal manifestations, Type II or unspecified type,                 X                X
     uncontrolled.............................................................
    250.43  Diabetes with renal manifestations, Type I, uncontrolled..........               X                X
    250.50  Diabetes with ophthalmic manifestations, Type II or unspecified                  X                X
     type, not stated as uncontrolled.........................................
    250.51  Diabetes with ophthalmic manifestations, Type I, not stated as                   X                X
     uncontrolled.............................................................
    250.52  Diabetes with ophthalmic manifestations, Type II or unspecified                  X                X
     type, uncontrolled.......................................................
    250.53  Diabetes with ophthalmic manifestations, Type I, uncontrolled.....               X                X
    250.60  Diabetes with neurological manifestations, Type II or unspecified                X                X
     type, not stated as uncontrolled.........................................
    250.61  Diabetes with neurological manifestations, Type I, not stated as                 X                X
     uncontrolled.............................................................
    250.62  Diabetes with neurological manifestations, Type II or unspecified                X                X
     type, uncontrolled.......................................................
    250.63  Diabetes with neurological manifestations, Type I uncontrolled....               X                X
    250.70  Diabetes with peripheral circulatory disorders, Type II or                       X                X
     unspecified type, not stated as uncontrolled.............................
    250.71  Diabetes with peripheral circulatory disorders, Type I, not stated               X                X
     as uncontrolled..........................................................
    250.72  Diabetes with peripheral circulatory disorders, Type II or                       X                X
     unspecified type, uncontrolled...........................................
    250.73  Diabetes with peripheral circulatory disorders, Type I,                          X                X
     uncontrolled.............................................................
    250.80  Diabetes with other specified manifestations, Type II or                         X                X
     unspecified type, not stated as uncontrolled.............................
    250.81  Diabetes with other specified manifestations, Type I, not states                 X                X
     as uncontrolled..........................................................
    250.82  Diabetes with other specified manifestations, Type II or                         X                X
     unspecified type, uncontrolled...........................................
    250.83  Diabetes with other specified manifestations, Type I, uncontrolled               X                X
    250.90  Diabetes with unspecified complication, Type II or unspecified                   X                X
     type, not states as uncontrolled.........................................
    250.91  Diabetes with unspecified complication, Type I, not stated as                    X                X
     uncontrolled.............................................................
    250.92  Diabetes with unspecified complication, Type II or unspecified                   X                X
     type, uncontrolled.......................................................
    250.93  Diabetes with unspecified complication, Type I, uncontrolled......               X                X
Principal or Secondary Diagnosis Code:
    585  Chronic renal failure................................................               X                X
    403.01  Hypertensive renal disease, malignant, with renal failure.........               X                X
    403.11  Hypertensive renal disease, benign, with renal failure............               X                X
    403.91  Hypertensive renal disease, unspecified, with renal failure.......               X                X
    404.02  Hypertensive heart & renal disease, malignant, with renal failure.               X                X
    404.03  Hypertensive heart & renal disease, malignant, with congestive                   X                X
     heart failure and renal disease..........................................
    404.12  Hypertensive heart & renal disease, benign, with renal failure....               X                X
    404.13  Hypertensive heart & renal disease, benign, with congestive heart                X                X
     failure and renal disease................................................
    404.92  Hypertensive heart & renal disease, unspecified, with renal                      X                X
     failure..................................................................
    404.93  Hypertensive heart & renal disease, unspecified, with congestive                 X                X
     heart failure and renal failure..........................................
    V42.0  Organ or tissue replaced by transplant, kidney.....................               X                X
    V43.89  Organ or tissue replaced by other means, other (Kidney)...........               X                X
Procedure Code:
    52.80  Pancreatic transplant, not otherwise specified.....................  ...............               X
    52.82  Homotransplant of pancreas.........................................  ...............               X
Combination Procedure Codes:
    52.80  Pancreatic transplant, not otherwise specified,
        Plus
    55.69  Other kidney transplantation.......................................               X   ...............
        Or
    52.82  Homotransplant of pancreas
        Plus
    55.69  Other kidney transplantation.......................................               X   ...............
----------------------------------------------------------------------------------------------------------------

    The logic for the DRG 512 accepts the pair of diagnosis codes in 
any position (principal/secondary or secondary/secondary). The pair of 
procedure codes must be present along with the two diagnosis codes. 
This DRG will be placed in the Pre-MDC GROUPER logic immediately 
following DRG 480 (Liver Transplant).
    The logic for DRG 513 accepts the pair of diagnosis codes in any 
position (principal/secondary or secondary/secondary). Only one 
procedure code must be used along with the two diagnosis codes. This 
DRG will be placed in the Pre-MDC GROUPER logic immediately following 
new DRG 512 (Simultaneous Pancreas/Kidney Transplant).
    We received two comments on this proposal. One commenter supported 
the creation of the two new DRGs; a summary of the other comment 
follows:
    Comment: One commenter noted that, as pancreas transplants were 
approved by Medicare on July 1, 1999, a special billing procedure 
should be made available to hospitals to enable hospitals to bill for 
the transplant DRG back to the effective date of the covered service.
    Response: DRGs 512 and 513 are effective for discharges occurring 
on or

[[Page 39857]]

after October 1, 2001, for FY 2002. Discharges involving pancreas 
transplants occurring prior to that time are assigned to existing DRGs 
as described above. Therefore, there is no need for hospitals to 
resubmit their bills.
    We are adopting the establishment of proposed DRGs 512 and 513 as 
final.
b. Intestinal Transplantation
    Effective April 1, 2001, Medicare covers intestinal transplantation 
for the purpose of restoring intestinal function in patients with 
irreversible intestinal failure (Medicare Program Memorandum 
Transmittal No. AB-01-58, April 12, 2001). This procedure is covered 
only when performed for patients who have failed total parenteral 
nutrition (TPN) and only when performed in centers that meet approval 
criteria.
    Intestinal failure is defined as the loss of absorptive capacity of 
the small bowel secondary to severe primary gastrointestinal disease or 
surgically induced short bowel syndrome. Intestinal failure prevents 
oral nutrition and may be associated with both mortality and profound 
morbidity.
    If an intestinal transplantation alone is performed on a patient 
with an intestinal principal diagnosis, the case would be assigned to 
either DRG 148 (Major Small & Large Bowel Procedures With CC) or DRG 
149 (Major Small & Large Bowel Procedures Without CC). If an intestinal 
transplantation and a liver transplantation are performed 
simultaneously, the case would be assigned to DRG 480 (Liver 
Transplant).
    If an intestinal transplantation alone is performed on a patient 
with an intestinal principal diagnosis, the case would be assigned to 
either DRG 148 (Major Small & Large Bowel Procedures with CC) or DRG 
149 (Major Small & Large Bowel Procedures Without CC). If an intestinal 
transplantation and a liver transplantation are performed 
simultaneously, the case would be assigned to DRG 480 (Liver 
Transplant).
    If an intestinal transplantation and a pancreas transplantation are 
performed simultaneously, currently the case would be assigned to 
either DRG 148 or DRG 149. Effective October 1, 2001, the case would be 
assigned to DRG 513 (Pancreas Transplant). We proposed to make a 
conforming change to the regulations at Sec. 412.2(e)(4) and 
Sec. 486.302 to include intestines (and multivisceral organs) in the 
list of organs for which Medicare pays for the acquisition costs on a 
reasonable cost basis.
    Effective October 1, 2000, procedure code 46.97 (Transplant of 
intestine) was created. For the proposed rule, we examined our Medicare 
claims data to determine whether it was appropriate to propose a new 
intestinal transplant DRG. We examined data in the FY 2000 MedPAR file 
containing bills submitted through May 31, 2000. Because procedure code 
46.97 was not in place during this time we focused our examination on 
the previous code assignment for intestinal transplant, code 46.99 
(Other operations on intestines), and facilities that are currently 
performing intestinal transplantation. We were able to identify only 
one case, with an average charge of approximately $10,738 as compared 
to the average standardized charges for DRGs 148 and 149, which are 
approximately $37,961, and $16,965, respectively. We will continue to 
monitor these cases to determine whether it may be appropriate in the 
future to establish a new DRG.
    Comment: One commenter recommended performing data analysis next 
year to determine if a separate intestinal transplantation DRG should 
be created based on the fact that these procedures are being performed 
on a more frequent basis. Another commenter suggested that the preamble 
specifically state that while the acquisition costs for heart, liver, 
lung, and pancreas transplants continue to be paid on a reasonable cost 
basis, the acquisition costs for intestinal transplantation will be 
paid through the hospital inpatient prospective payment system DRG 
payment mechanism.
    Response: It is our intent to continue to monitor these cases to 
determine whether it may be appropriate in the future to establish a 
new DRG.
    To clarify the issue of acquisition costs, Medicare Program 
Memorandum Transmittal No. AB-01-58, released April 12, 2001, states 
that Medicare will not pay transplant facilities on a reasonable cost 
basis for organ acquisition for intestinal or multivisceral 
transplants. The DRG payment will be payment in full for hospital 
services related to this procedure. However, in this final rule, we are 
implementing a conforming change to the regulations at Sec. 412.2(e)(4) 
and Sec. 486.302, to include intestines (and multivisceral organs) in 
the list of organs for which Medicare pays for the acquisition costs on 
a reasonable cost basis. This change is effective with acquisition 
costs incurred on or after October 1, 2001. After that date, costs 
associated with the acquisition of intestines and multivisceral organs 
will be paid on a reasonable cost basis. Costs associated with 
intestines procured separately will be allocated to an intestine cost 
center and allocated on Worksheet D-6. Multivisceral organ 
transplantation includes organs in the digestive system (that is, 
stomach, duodenum, pancreas, liver, intestine, and colon). 
Multivisceral procurements, including an organ(s) as defined at 
Sec. 486.302 as well as the intestine (small bowel), will be allocated 
to the intestinal acquisition cost center. Multivisceral procurements 
are procured en bloc and the entire cost of procuring all of the organs 
will be allocated to the intestinal acquisition cost center.
c. Payment for Blood Clotting Factor Administered to Hemophilia 
Inpatients
    Comment: Although this issue was not addressed in the proposed 
rule, we received one comment requesting that the add-on payment for 
blood clotting factors administered to hemophilia inpatients include 
adequate reimbursement for hospitals that treat beneficiaries with 
acquired hemophilia.
    Response: According to section 4452 of Public Law 105-33, which 
amended section 6011(d) of Public Law 101-239, prospective payment 
hospitals receive an additional payment for costs of administering 
blood clotting factor to Medicare hemophiliacs who are hospital 
inpatients.
    Hemophilia, a bleeding disorder characterized by prolonged clotting 
time, is caused by a deficiency of a factor necessary for blood to 
clot. In the August 29, 1997 final rule implementing section 4452 of 
Public Law 105-33 (62 FR 46002), we stated that hemophilia was 
considered to encompass the following conditions: Factor VIII 
deficiency (classical hemophilia); Factor IX deficiency (also termed 
plasma thromboplastin component (PTC) or Christmas factor deficiency); 
and Von Willebrand's disease. The most common factors required by 
hemophiliacs to increase coagulation are Factor VIII and Factor IX; a 
small number of hemophiliacs have developed inhibitors to these factors 
and require special treatment. We did not receive any comments 
regarding this coverage until, most recently, the cases of acquired 
hemophilia, which affects a small subset of individuals (1 in 1 
million), were brought to our attention.
    We are revising our claims processing instructions to permit add-on 
payments for the following ICD-9-CM diagnosis codes associated with 
acquired hemophilia:

286.5  Hemorrhagic disorder due to circulating anticoagulants
286.7  Acquired coagulation factor deficiency.

[[Page 39858]]

C. Recalibration of DRG Weights

    We proposed to use the same basic methodology for the FY 2002 
recalibration as we did for FY 2001 (August 1, 2000 final rule (65 FR 
47069)). That is, we would recalibrate the weights based on charge data 
for Medicare discharges. However, we proposed to use the most current 
charge information available, the FY 2000 MedPAR file. (For the FY 2001 
recalibration, we used the FY 1999 MedPAR file.) The MedPAR file is 
based on fully coded diagnostic and procedure data for all Medicare 
inpatient hospital bills.
    The final recalibrated DRG relative weights are constructed from FY 
2000 MedPAR data (discharges occurring between October 1, 1999 and 
September 30, 2000), based on bills received by CMS through March 31, 
2001, from all hospitals subject to the prospective payment system and 
short-term acute care hospitals in waiver States. The FY 2000 MedPAR 
file includes data for approximately 11,094,323 Medicare discharges.
    The methodology used to calculate the DRG relative weights from the 
FY 2000 MedPAR file is as follows:
     To the extent possible, all the claims were regrouped 
using the DRG classification revisions discussed in section II.B. of 
this preamble.
     Charges were standardized to remove the effects of 
differences in area wage levels, indirect medical education and 
disproportionate share payments, and, for hospitals in Alaska and 
Hawaii, the applicable cost-of-living adjustment.
     The average standardized charge per DRG was calculated by 
summing the standardized charges for all cases in the DRG and dividing 
that amount by the number of cases classified in the DRG.
     We then eliminated statistical outliers, using the same 
criteria used in computing the current weights. That is, all cases that 
are outside of 3.0 standard deviations from the mean of the log 
distribution of both the charges per case and the charges per day for 
each DRG are eliminated.
     The average charge for each DRG was then recomputed 
(excluding the statistical outliers) and divided by the national 
average standardized charge per case to determine the relative weight. 
A transfer case is counted as a fraction of a case based on the ratio 
of its transfer payment under the per diem payment methodology to the 
full DRG payment for nontransfer cases. That is, transfer cases paid 
under the transfer methodology equal to half of what the case would 
receive as a nontransfer would be counted as 0.5 of a total case.
     We established the relative weight for heart and heart-
lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner 
consistent with the methodology for all other DRGs except that the 
transplant cases that were used to establish the weights were limited 
to those Medicare-approved heart, heart-lung, liver, and lung 
transplant centers that have cases in the FY 1999 MedPAR file. 
(Medicare coverage for heart, heart-lung, liver, and lung transplants 
is limited to those facilities that have received approval from CMS as 
transplant centers.)
     Acquisition costs for kidney, heart, heart-lung, liver, 
lung, and pancreas transplants continue to be paid on a reasonable cost 
basis. Unlike other excluded costs, the acquisition costs are 
concentrated in specific DRGs: DRG 302 (Kidney Transplant); DRG 103 
(Heart Transplant); DRG 480 (Liver Transplant); DRG 495 (Lung 
Transplant); and proposed new DRGs 512 (Simultaneous Pancreas/Kidney 
Transplant) and 513 (Pancreas Transplant). Because these costs are paid 
separately from the prospective payment rate, it is necessary to make 
an adjustment to prevent the relative weights for these DRGs from 
including the acquisition costs. Therefore, we subtracted the 
acquisition charges from the total charges on each transplant bill that 
showed acquisition charges before computing the average charge for the 
DRG and before eliminating statistical outliers.
    When we recalibrated the DRG weights for previous years, we set a 
threshold of 10 cases as the minimum number of cases required to 
compute a reasonable weight. We use that same case threshold in 
recalibrating the DRG weights for FY 2002. Using the FY 2000 MedPAR 
data set, there are 37 DRGs that contain fewer than 10 cases. We 
computed the weights for these 37 low-volume DRGs by adjusting the FY 
2001 weights of these DRGs by the percentage change in the average 
weight of the cases in the other DRGs.
    The new weights are normalized by an adjustment factor (1.44556) so 
that the average case weight after recalibration is equal to the 
average case weight before recalibration. This adjustment is intended 
to ensure that recalibration by itself neither increases nor decreases 
total payments under the prospective payment system, and accounts for 
the gradual shift in cases toward higher-weighted DRGs over time.
    We received no comments on DRG recalibration.
    Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with 
FY 1991, reclassification and recalibration changes be made in a manner 
that assures that the aggregate payments are neither greater than nor 
less than the aggregate payments that would have been made without the 
changes. Although normalization is intended to achieve this effect, 
equating the average case weight after recalibration to the average 
case weight before recalibration does not necessarily achieve budget 
neutrality with respect to aggregate payments to hospitals because 
payment to hospitals is affected by factors other than average case 
weight. Therefore, as we have done in past years and as discussed in 
section II.A.4.a. of the Addendum to the final rule, we make a budget 
neutrality adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.

III. Changes to the Hospital Wage Index

A. Background

    Section 1886(d)(3)(E) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals, the 
Secretary must adjust the standardized amounts ``for area differences 
in hospital wage levels by a factor (established by the Secretary) 
reflecting the relative hospital wage level in the geographic area of 
the hospital compared to the national average hospital wage level.'' In 
accordance with the broad discretion conferred under the Act, we 
currently define hospital labor market areas based on the definitions 
of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New 
England County Metropolitan Areas (NECMAs) issued by the Office of 
Management and Budget (OMB). The OMB also designates Consolidated MSAs 
(CMSAs). A CMSA is a metropolitan area with a population of one million 
or more, comprising two or more PMSAs (identified by their separate 
economic and social character). For purposes of the hospital wage 
index, we use the PMSAs rather than CMSAs since they allow a more 
precise breakdown of labor costs. If a metropolitan area is not 
designated as part of a PMSA, we use the applicable MSA. Rural areas 
are areas outside a designated MSA, PMSA, or NECMA. For purposes of the 
wage index, we combine all of the rural counties in a State to 
calculate a rural wage index for that State.
    We note that, effective April 1, 1990, the term Metropolitan Area 
(MA) replaced the term MSA (which had been used since June 30, 1983) to 
describe the set of metropolitan areas consisting of MSAs, PMSAs, and 
CMSAs. The terminology was changed by OMB in

[[Page 39859]]

the March 30, 1990 Federal Register to distinguish between the 
individual metropolitan areas known as MSAs and the set of all 
metropolitan areas (MSAs, PMSAs, and CMSAs) (55 FR 12154). For purposes 
of the prospective payment system, we will continue to refer to these 
areas as MSAs.
    Beginning October 1, 1993, section 1886(d)(3)(E) of the Act 
requires that we update the wage index annually. Furthermore, this 
section provides that the Secretary base the update on a survey of 
wages and wage-related costs of short-term, acute care hospitals. The 
survey should measure, to the extent feasible, the earnings and paid 
hours of employment by occupational category, and must exclude the 
wages and wage-related costs incurred in furnishing skilled nursing 
services. As discussed below in section III.F. of this preamble, we 
also take into account the geographic reclassification of hospitals in 
accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when 
calculating the wage index.

B. FY 2002 Wage Index Update

    The FY 2002 wage index values in section V of the Addendum to this 
final rule (effective for hospital discharges occurring on or after 
October 1, 2001 and before October 1, 2002) are based on the data 
collected from the Medicare cost reports submitted by hospitals for 
cost reporting periods beginning in FY 1998 (the FY 2001 wage index was 
based on FY 1997 wage data).
    The final FY 2002 wage index includes the following categories of 
data associated with costs paid under the hospital inpatient 
prospective payment system (as well as outpatient costs), which were 
also included in the FY 2001 wage index:
     Salaries and hours from short-term, acute care hospitals.
     Home office costs and hours.
     Certain contract labor costs and hours.
     Wage-related costs.
    Consistent with the wage index methodology for FY 2001, the wage 
index for FY 2002 also continues to exclude the direct and overhead 
salaries and hours for services not paid through the inpatient 
prospective payment system such as skilled nursing facility (SNF) 
services, home health services, or other subprovider components that 
are not subject to the prospective payment system.
    We calculate a separate Puerto Rico-specific wage index and apply 
it to the Puerto Rico standardized amount. (See 62 FR 45984 and 46041.) 
This wage index is based solely on Puerto Rico's data. Finally, section 
4410 of Public Law 105-33 provides that, for discharges on or after 
October 1, 1997, the area wage index applicable to any hospital that is 
not located in a rural area may not be less than the area wage index 
applicable to hospitals located in rural areas in that State.

C. FY 2002 Wage Index

    Because the hospital wage index is used to adjust payments to 
hospitals under the prospective payment system, the wage index should, 
to the extent possible, reflect the wage costs associated with the 
areas of the hospital included under the hospital inpatient prospective 
payment system. In response to concerns within the hospital community 
related to the removal, from the wage index calculation, of costs 
related to graduate medical education (GME) (teaching physicians and 
residents) and certified registered nurse anesthetists (CRNAs), which 
are paid by Medicare separately from the prospective payment system, 
the AHA convened a workgroup to develop a consensus recommendation on 
this issue. The workgroup recommended that costs related to GME and 
CRNAs be phased out of the wage index calculation over a 5-year period. 
Based upon our analysis of hospitals' FY 1996 wage data, and consistent 
with the AHA workgroup's recommendation, we specified in the July 30, 
1999 final rule (64 FR 41505) that we would phase-out these costs from 
the calculation of the wage index over a 5-year period, beginning in FY 
2000. In keeping with the decision to phase-out costs related to GME 
and CRNAs, the final FY 2002 wage index is based on a blend of 40 
percent of an average hourly wage including these costs, and 60 percent 
of an average hourly wage excluding these costs.
    Beginning with the FY 1998 cost reports, we revised the Worksheet 
S-3, Part II so that hospitals can separately report teaching physician 
Part A costs on lines 4.01, 10.01, 12.01, and 18.01. Therefore, it is 
no longer necessary for us to conduct the special survey we used for 
the FY 2000 and FY 2001 wage indexes (64 FR 41505 and 65 FR 47071).
1. Health Insurance and Health-Related Costs
    In the August 1, 2000 final rule, we clarified our definition of 
``purchased health insurance costs'' and ``self-insurance'' for 
hospitals that provide health insurance to employees (65 FR 47073). For 
purposes of the wage index, purchased or self-funded health insurance 
plan costs include the hospitals' insurance premium costs, external 
administration costs, and the share of costs for services delivered to 
employees.
    In response to a comment received concerning this issue, we stated 
that, for self-funded health insurance costs, personnel costs 
associated with hospital staff that deliver the services to the 
employees must continue to be excluded from wage-related costs if the 
costs are already included in the wage data as salaries on Worksheet S-
3, Part II, Line 1. However, after further consideration of this 
policy, particularly with respect to concerns expressed by our fiscal 
intermediaries about the level of effort required during the wage index 
desk review process to ensure hospitals are appropriately identifying 
and excluding these costs, in the May 4, 2001 proposed rule we proposed 
a revision. Effective with the calculation of the FY 2003 wage index, 
for either purchased or self-funded health insurance, we proposed to 
allow personnel costs associated with hospital staff who deliver 
services to employees to be included as part of the wage-related costs. 
We believe the proposed revised policy will ensure that health 
insurance costs are consistently reported by hospitals. Health 
insurance costs would continue to be developed using generally accepted 
accounting principles.
    In the August 1, 2000 final rule (65 FR 47073), we further 
clarified that health-related costs (including employee physical 
examinations, flu shots, and clinic visits, and other services that are 
not covered by employees' health insurance plans but are provided at no 
cost or at discounted rates to employees of the hospital) may be 
included as ``other'' wage-related costs if, among other criteria, the 
combined cost of all such health-related costs is greater than one 
percent of the hospital's total salaries (less excluded area salaries).
    For purposes of calculating the FY 2003 wage index (which will be 
based on data for cost reporting periods beginning in FY 1999), we 
proposed to revise this policy to allow hospitals to include health-
related costs as allowable core wage-related costs.
    Comment: One commenter supported our proposal to include health-
related costs as core wage-related costs. The commenter also agreed 
with our proposal to include all personnel costs associated with 
hospital staff who deliver health services to employees. However, the 
commenter expressed concern that the proposed changes would require 
burdensome and duplicative revisions to cost reports that have already 
been filed.
    Response: We believe that these revised policies (to eliminate the

[[Page 39860]]

distinction between purchased health insurance and self-funded health 
insurance, and to treat costs associated with health-related services 
that are not part of the employees' health insurance plan consistent 
with costs included in the plan) will ensure that these costs are 
treated consistently across hospitals and fiscal intermediaries.
    In response to the commenter's concern that the policy will require 
revisions to previously submitted cost reports, we believe the changes 
are not significant, particularly in light of the volume of changes 
submitted every year by hospitals during the wage data review process 
(see discussion in section III.G. of this final rule). The cost report 
changes necessary to implement these policy changes involve including 
costs previously disallowed. In the case of personnel costs associated 
with hospital staff who deliver services to employees, these costs 
would have already been identified in order to be excluded from the 
wage data. With respect to health services provided outside the 
employees' health insurance plan, we acknowledge that some hospitals 
may not have tracked these costs because they did not qualify for 
inclusion as other wage-related costs. However, due to concerns 
expressed by fiscal intermediaries about the difficulty of identifying 
these costs separate from those that are part of the insurance plan, we 
believe there may be inconsistencies in the current data with regard to 
how these costs are treated. Therefore, we believe, in the interest of 
improving the consistency of the data, that we should begin to allow 
these costs as core wage-related costs effective with the FY 2003 wage 
index.
2. Costs of Contracted Pharmacy and Laboratory Services
    Our policy concerning inclusion of contract labor costs for 
purposes of calculating the wage index has evolved over the years. We 
recognize the role of contract labor in meeting special personnel needs 
of many hospitals. In addition, improvements in the wage data have 
allowed us to more accurately identify contract labor costs and hours. 
As a result, effective with the FY 1994 wage index, we included the 
costs of direct patient care contract services in the wage index 
calculation. The FY 1999 wage index included the costs and hours of 
certain management contract services, and the FY 2000 wage index 
included the costs for contract physician Part A services. (The 1996 
proposed rule (61 FR 27456) provided an in-depth background to the 
issues related to the inclusion of contract labor costs in the wage 
index calculation.)
    We revised the 1998 cost report to collect the data associated with 
contract pharmacy, Worksheet S-3, Part II, Line 9.01, and contract 
laboratory, Worksheet S-3, Part II, Line 9.02. The cost reporting 
instructions for these line numbers followed that for all contract 
labor lines; that is, to include the amount paid for services furnished 
under contract for direct patient care, and not include cost for 
equipment, supplies, travel expenses, and other miscellaneous or 
overhead items (Medicare Provider Reimbursement Manual, Part 2, Cost 
Reporting Forms and Instructions, Chapter 36, Transmittal 6, pages 36-
32). Effective with the FY 2002 wage index, which uses FY 1998 wage 
data, we are including in this final rule (as proposed in the May 4 
proposed rule) the costs and hours of contract pharmacy and laboratory 
services.
    Comment: Two commenters supported our proposed policy to include 
the costs and hours of contract pharmacy and laboratory as direct 
patient care contract labor in the FY 2002 wage index. However, both 
commenters recommended that clearer guidelines be provided to ensure 
consistency in interpretation by fiscal intermediaries and contract 
vendors.
    Response: Beginning with the FY 2002 wage index, we are including 
the costs and hours of contract pharmacy and laboratory services in the 
calculation of the wage index. Further instructions for reporting 
contract pharmacy and laboratory costs will be included in Transmittal 
8 of the cost report, due for release in early fall 2001.
3. Collection of Occupational Mix Data
    Section 304(c) of Public Law 106-554 amended section 1886(d)(3)(E) 
of the Act to require that the Secretary must provide for the 
collection of data every 3 years on the occupational mix of employees 
for each short-term, acute care hospital participating in the Medicare 
program, in order to construct an occupational mix adjustment to the 
wage index. The initial collection of these data must be completed by 
September 30, 2003, for application beginning October 1, 2004.
    Currently, the wage data collected on the cost report reflect the 
sum of wages, hours, and wage-related costs for all hospital employees. 
There is no separate collection by occupational categories of 
employees, such as registered nurses or physical therapists. Total 
salaries and hours reflect management decisions made by hospitals in 
terms of how many employees within a certain occupation to employ to 
treat different types of patients. For example, a large academic 
medical center may tend to hire more high-cost specialized employees to 
treat its more acutely ill patient population. The argument is that the 
higher labor costs incurred to treat this patient population are 
reflected in the higher case mix of these hospitals, and therefore, 
reflecting these costs in the wage index is essentially counting them 
twice.
    An occupational mix adjustment can be used to account for hospital 
management decisions about how many employees to hire in each 
occupational category. Occupational mix data measure the price the 
hospital must pay for employees within each category. A wage index that 
reflected only these market prices would remove the impact of 
management decisions about the mix of employees needed and, therefore, 
better capture geographic variations in the labor market.
    We have examined this issue previously. In the May 27, 1994 Federal 
Register (59 FR 27724), we discussed the outcome of consideration of 
this issue by a hospital workgroup. At that time, the workgroup's 
consensus was that the data required to implement an occupational mix 
adjustment were not available and the likelihood of obtaining such data 
would be minimal. There seemed to be little support among hospital 
industry representatives for developing a system that would create 
additional reporting burdens with an unproven or minimal impact on the 
distribution of payments. Also, in the August 30, 1991 Federal Register 
(56 FR 43219), we stated our belief that the collection of these data 
would be costly and difficult.
    In considering the format to collect occupational mix data, we 
looked to data currently being collected by the Bureau of Labor 
Statistics (BLS), which conducts an annual mail survey to produce 
estimates of employment and wages for specific occupations. This 
program, Occupational Employment Statistics (OES), collects data on 
wage and salary workers in nonfarm establishments in order to produce 
employment and wage estimates for over 700 occupations.
    The OES survey collects wage data in 12 hourly rate intervals. 
Employers report the number of employees in an occupation per each wage 
range. To illustrate, the wage intervals used for the 1999 survey are 
as follows:

[[Page 39861]]



----------------------------------------------------------------------------------------------------------------
                Interval                           Hourly wages                        Annual wages
----------------------------------------------------------------------------------------------------------------
Range A................................  Under $6.75....................  Under $14,040.
Range B................................  $6.75 to $8.49.................  $14,040 to $17,659.
Range C................................  8.50 to 10.74..................  17,660 to 22,359.
Range D................................  10.75 to 13.49.................  22,360 to 28,079.
Range E................................  13.50 to 16.99.................  28,080 to 35,359.
Range F................................  17.00 to 21.49.................  35,360 to 44,719.
Range G................................  21.50 to 27.24.................  44,720 to 56,679.
Range H................................  27.25 to 34.49.................  56,680 to 71,759.
Range I................................  34.50 to 43.74.................  71,760 to 90,999.
Range J................................  43.75 to 55.49.................  91,000 to 115,439.
Range K................................  55.50 to 69.99.................  115,440 to 145,599.
Range L................................  70.00 and over.................  145,600 and over.
----------------------------------------------------------------------------------------------------------------

    We noted that this table is for illustrative purposes, and that we 
may update the data ranges in our actual collection instrument.
    Although we initially considered using the OES data, section 304(c) 
of Public Law 106-554 requires us to collect data from every short-
term, acute care hospital. The OES data are a sample survey and, 
therefore, as currently conducted, are not consistent with the 
statutory requirement to include data from every hospital. Another 
issue with using OES data is that, for purposes of the Medicare wage 
index, the hospitals' data must be reviewed and verified by the fiscal 
intermediaries. The OES survey is a voluntary survey for most States.
    Although we decided to pursue a separate data collection effort 
than OES, we proposed in the May 4, 2001 proposed rule to model our 
format after the one used by OES. In this way, hospitals participating 
in the OES survey would have no additional recordkeeping and reporting 
requirements beyond those of the OES survey.
    The OES survey of the hospital industry is designed to capture all 
occupational categories within the industry. For purposes of adjusting 
the wage index for occupational mix, we do not believe it is necessary 
to collect data from such a comprehensive scope of categories. 
Furthermore, because the data must be audited, a comprehensive list of 
categories would be excessively burdensome.
    In deciding which occupational categories to include, we reviewed 
the occupational categories collected by OES and identified those with 
at least 35,000 hospital employees. Our goal is to collect data from a 
sample of occupational categories that provides a valid measure of wage 
rates within a geographical area. In the May 4 proposed rule, using 
this threshold of at least 35,000 employees within a category 
nationally, we proposed to collect data on the number of employees by 
wage range as illustrated in the above table, for the occupational 
categories listed below. The following data, which was also listed in 
the proposed rule, are based on the 1998 OES survey. (These data are no 
longer available on the internet.)

----------------------------------------------------------------------------------------------------------------
                                                                                        Percent of
                                                                           Number of       total         Mean
                OES code                             Category              employees     hospital       hourly
                                                                                         employees       wage
----------------------------------------------------------------------------------------------------------------
15008..................................  Medicine and Health Services          93,680          1.9        $27.38
                                          Manager.
27302..................................  Social Workers, Medical and           53,360          1.1         16.33
                                          Psychiatric.
32102..................................  Physicians and Surgeons........      125,640          2.6         43.76
32308..................................  Physical Therapists............       39,840          0.8         26.14
32502..................................  Registered Nurses..............    1,231,980         25.0         21.12
32505..................................  Licensed Practical Nurses......      206,360          4.2         13.39
32517..................................  Pharmacists....................       46,860          1.0         28.62
32911, 32928, and 32931................  Clinical Technologists and           122,380          2.50        11.69
                                          Technicians.
51002, 55105, 55108, 55305, 55332, and   First-Line Supervisors and           445,730          9.5         11.39
 55347.                                   Clerical Workers.
65038, 67002, and 67005................  Food Preparation Workers and         218,440          4.5          8.17
                                          Housekeeping.
66008..................................  Nursing Aides, Orderlies, and        301,240          6.2          8.67
                                          Attendants.
----------------------------------------------------------------------------------------------------------------

    We proposed that this list of occupational categories provides a 
good representation of the employee mix at most hospitals. It has since 
come to our attention that the occupational categories listed in the 
proposed rule have been replaced by Standard Occupational Category 
definitions.
    Because we had not yet settled on the methodology to use the 
occupational mix data in the wage index, we discussed in the proposed 
rule one option to weight each hospital's wage index by its 
occupational mix index. This requires calculating a national 
occupational mix index and then breaking it down by MSA and by 
hospital, similar to how the wage index is broken down. In this way, 
the wage index would capture geographic differences in wage rates. The 
decision about how to apply the occupational mix index to the wage 
index depends on the quality of the data collected, since this effort 
will be the first time wage and hour data by occupation are collected 
in this audited manner.
    Section 304(c) directs the Secretary to provide for the collection 
of these data by September 30, 2003, and to apply them in the wage 
index by October 1, 2004. Therefore, the data are to be incorporated in 
the FY 2005 wage index. Under our current timetable, the FY 2005 wage 
index will be based on wage data collected from hospitals' cost 
reporting periods beginning during FY 2001. In order to facilitate the 
fiscal intermediaries' review of these data, we believe the 
occupational mix data should coincide with the data otherwise

[[Page 39862]]

used to calculate the cost report. Therefore, we will conduct a special 
survey of all short-term acute-care hospitals that are required to 
report wage data to collect these data coinciding with hospitals' FY 
2001 cost reports.
    Comment: Several commenters expressed interest in working with us 
to develop an appropriate data collection tool. They suggested that the 
data be relatively simple for hospitals to gather and submit, and 
should be collected on 100 percent of hospital employees. Another 
commenter recommended that, at least initially, only data on nursing 
categories would be sufficient since nurses are 35 percent of hospital 
employees and can be divided into a few easily distinguishable 
categories. Two commenters offered examples for how these data are 
collected in their area. Some commenters wanted these data incorporated 
in the cost report to limit the number of forms hospitals must complete 
and to improve the response rate.
    Response: We agree that it would be beneficial to work with the 
industry to develop a workable data collection tool, especially given 
the importance of the wage index in adjusting hospital payments. We 
appreciate the comments on the option presented in the proposed rule 
and believe that these comments will help initiate further thought 
toward the development of an occupational mix survey that can be 
administered without excessive burden on hospitals, the fiscal 
intermediaries, or CMS.
    Due to time constraints in meeting the statutory deadlines, our 
intention at this point is to attempt to develop a survey instrument 
for the initial collection of occupational mix data that can be used by 
hospitals during calendar year 2002. Therefore, prior to January 1, 
2002, we plan to work with the hospital community to develop a survey 
instrument. We believe issues related to the sample size of the data 
collected and the appropriate occupational categories to collect can 
best be resolved through consultation with the industry. Therefore, we 
will be contacting those organizations that expressed an interest in 
consultation in their comments. Other interested parties are encouraged 
to contact us as well.
    After developing a method that appropriately balances the need to 
collect accurate and reliable data with the need to collect data 
hospitals can be reasonably expected to have available, we will issue 
instructions as to the type of data to be collected, in advance of 
actually requiring hospitals to begin providing the data.
    Comment: Some commenters asked us to further develop the planned 
use of the occupation information and then decide what information is 
required. They requested that we publish the projected economic effects 
of an occupational mix adjustment upon each hospital as soon as 
feasible, and demonstrate tangible benefits prior to requiring 
hospitals to collect data. One commenter offered a specific methodology 
that could be employed. Other commenters want the methodology phased-in 
over time to allow hospitals time to adjust to different payment 
levels.
    Response: In the proposed rule, we stated that we had not yet 
settled on the actual methodology for using the occupational mix data 
in the calculation of the wage index. We indicated the decision as to 
how the data will be used is dependent on the quality of the data 
collected. That is still the case. Furthermore, as discussed above, we 
intend to develop an appropriate data collection instrument in 
consultation with the hospital community. Therefore, until decisions 
are made with regard to the specific data to be collected, we cannot 
specify how the data will be used. However, the selection of an 
appropriate methodology (including a possible phase-in) will be 
influenced by analysis of the impacts of the method on hospital 
payments.
    Comment: Two commenters expressed concerns that adopting the 
occupational mix adjustment for the wage index will lower the average 
hourly wage of teaching hospitals because of their mix of highly 
skilled, higher paid employees to treat patients with more complex 
conditions. These commenters argued that implementation of the 
occupational mix adjustment should proceed only in conjunction with the 
adoption of severity-adjusted DRGs. These commenters wrote that the 
current DRG system does not adequately recognize patient severity and 
pay for the higher resource costs associated with complex patients, but 
teaching hospitals can recoup some of these losses because their higher 
employee skill mix is reflected in their average hourly wage.
    Furthermore, one commenter countered the argument that the higher 
labor costs incurred to treat a more severely ill patient population 
are reflected in the higher case mix of these hospitals and, therefore, 
reflecting these costs in the wage index is essentially counting them 
twice. This commenter pointed out that, because the DRG weights are 
based on hospital charges that are standardized by, among other 
factors, the area wage index, the weights of tertiary care DRGs are 
lower than they would be if the average charge per case were not first 
standardized by the wage index. However, the commenter went on to state 
that it is preferable to account for skill mix in the wage index rather 
than the case-mix index.
    Response: As we stated in the August 1, 2000 final rule (65 FR 
47103), we agree that severity-adjusted DRGs have potential for 
reducing discrepancies between payments and costs for individual cases 
(60 FR 29246). We have stated that, prior to implementing severity-
adjusted DRGs, we would need specific legislative authority to offset 
any significant anticipated increase in payments attributable to 
changes in coding practices caused by significant changes to the DRG 
classification system. Section 301 of Public Law 106-554 authorized the 
Secretary to adjust the average standardized amounts if he determines 
that DRG coding or classification changes are likely to result in a 
change in aggregate payments. Therefore, based on this authority, we 
are beginning to evaluate the potential for implementing severity-
adjusted DRGs. Because we are at the initial stages of that effort, we 
cannot yet estimate when, or if, such implementation may occur. 
However, we agree with these commenters' points that significant 
changes to any of the adjustments under the prospective payment system 
must be considered in light of the effects such changes may have to 
other such adjustments.
    Comment: One commenter interpreted our proposal to suggest that the 
fiscal year for which the data will be collected will be closed by the 
time the methodology and data requirements have been established.
    Response: In the proposed rule, we indicated we would conduct a 
special survey to collect these data to coincide with hospitals' cost 
reports beginning during FY 2001. We do not intend to require hospitals 
to retroactively adjust their payroll records to collect these data. 
Therefore, given our intention to gather input from the industry prior 
to designing the survey instrument, it likely will not be possible to 
completely coincide the data collection period with hospitals' FY 2001 
cost reports.
    Although there may be some auditing benefits to having the data 
overlap, this type of data is not routinely collected through the cost 
reports, so that the auditing benefits of such overlap may be minimal. 
In addition, there may be a benefit to collecting occupational mix for 
a more recent period in terms of reflecting current trends, such as 
higher wages paid to nurses during a shortage.

[[Page 39863]]

    Comment: Other commenters raised specific technical concerns about 
the occupational mix discussion in the proposed rule.
    Response: Rather than respond individually at this time to 
technical issues associated with the occupational mix discussion in the 
proposed rule, we will address these issues through direct consultation 
with the industry, as described above.

D. Verification of Wage Data From the Medicare Cost Report

    The data for the FY 2002 wage index were obtained from Worksheet S-
3, Parts II and III of the FY 1998 Medicare cost reports. The data file 
used to construct the wage index includes FY 1998 data submitted to us 
as of July 2001. As in past years, we performed an intensive review of 
the wage data, mostly through the use of edits designed to identify 
aberrant data.
    We asked our fiscal intermediaries to revise or verify data 
elements that resulted in specific edit failures. The unresolved data 
elements that were included in the calculation of the proposed FY 2002 
wage index have been resolved and are reflected in the calculation of 
the final FY 2002 wage index. We note that, as part of this process to 
identify aberrant data and correct any errors prior to the calculation 
of the final FY 2002 wage index, we notified by letter those hospitals 
that were leading to large variations in the wage indexes of their 
labor market areas compared to the FY 2001 wage index. These hospitals 
were advised to review their data to identify the reason for the large 
increases or decreases and notify their fiscal intermediary of any 
necessary corrections.
    Also, as part of our editing process, in the final wage index, we 
removed data for 30 hospitals that failed edits. For 24 of these 
hospitals, we were unable to obtain sufficient documentation to verify 
or revise the data because the hospitals are no longer participating in 
the Medicare program or are in bankruptcy status. Six hospitals had 
incomplete or inaccurate data resulting in exceptionally large, zero, 
or negative average hourly wages. Therefore, they were removed from the 
calculation. As a result, the final FY 2002 wage index is calculated 
based on FY 1998 wage data for 4,880 hospitals.
    Comment: One commenter recommended that we incorporate additional 
fatal edits in the cost reporting systems to eliminate obvious errors 
on the Worksheet S-3 that result in incomplete or erroneous wage data 
that are difficult to correct 4 years later.
    Response: We do not agree with the recommendation of the commenter. 
A separate desk review is performed for the wage index. The desk 
review, combined with the level two edits, is sufficient to provide 
fiscal intermediaries with information to identify discrepancies, such 
as zero or negative average hourly wage or missing hours, that can be 
resolved by the fiscal intermediary during the cost reporting process.

E. Computation of the FY 2002 Wage Index

    We note a technical change to the FY 2002 calculation. For the FY 
2001 wage index calculation, we initially proposed to subtract Line 13 
of Worksheet S-3, Part III from total hours when determining the 
excluded hours ratio used to estimate the amount of overhead attributed 
to excluded areas (65 FR 26299). However, the formula resulted in large 
and inappropriate increases in the average hourly wages for some 
hospitals (65 FR 47074), particularly hospitals that have large 
overhead and excluded area costs. Therefore, for the final FY 2001 wage 
index calculation, we reverted to the FY 2000 excluded hours ratio 
formula, which did not subtract Line 13.
    Subsequently, we analyzed how the application of this formula 
resulted in overstated average hourly wages for some hospitals and how 
we could improve the overall accuracy of the overhead allocation 
methodology. We became aware that the problem was not in the excluded 
hours ratio formula. Rather, our wage index calculation did not also 
remove the overhead wage-related costs associated with excluded areas, 
an amount that must be estimated before it can be subtracted from the 
calculation. The combined effect of applying the excluded hours ratio 
formula, which appropriately removes salaries of lower-wage, overhead 
employees, and not subtracting overhead wage-related costs associated 
with excluded areas, resulted in overstated salary costs and average 
hourly wages.
    For the FY 2002 wage index calculation, we are applying the 
excluded hours ratio formula that subtracts Part III, Line 13 from 
total hours. Additionally, for the first time in the wage index 
calculation, we estimated and subtracted overhead wage-related costs 
allocated to excluded areas.
    After we applied this new calculation, there were still a few 
hospitals that experienced large increases in their average hourly 
wages. The intermediaries verified that the hospitals' wage data were 
accurate, so we kept the data in the wage index calculation. These 
hospitals primarily function as SNFs, psychiatric hospitals, or 
rehabilitation hospitals that have few acute care beds. The hospitals' 
higher average hourly wages reflect the costs of the higher salaried 
employees that remain in the wage index calculation after we subtract 
the costs of excluded area and associated overhead employees.
    The method used to compute the final FY 2002 wage index follows.
    Step 1--As noted above, we based the FY 2002 wage index on wage 
data reported on the FY 1998 Medicare cost reports. We gathered data 
from each of the non-Federal, short-term, acute care hospitals for 
which data were reported on the Worksheet S-3, Parts II and III of the 
Medicare cost report for the hospital's cost reporting period beginning 
on or after October 1, 1997 and before October 1, 1998. In addition, we 
included data from any hospital that had cost reporting periods 
beginning before October 1997 and reported a cost reporting period 
covering all of FY 1998. These data were included because no other data 
from these hospitals would be available for the cost reporting period 
described above, and because particular labor market areas might be 
affected due to the omission of these hospitals. However, we generally 
describe these wage data as FY 1998 data. We note that, if a hospital 
had more than one cost reporting period beginning during FY 1998 (for 
example, a hospital had two short cost reporting periods beginning on 
or after October 1, 1997 and before October 1, 1998), we included wage 
data from only one of the cost reporting periods, the longest, in the 
wage index calculation. If there was more than one cost reporting 
period and the periods were equal in length, we included the wage data 
from the latest period in the wage index calculation.
    Step 2--Salaries--The method used to compute a hospital's average 
hourly wage is a blend of 40 percent of the hospital's average hourly 
wage including all GME and CRNA costs, and 60 percent of the hospital's 
average hourly wage after eliminating all GME and CRNA costs.
    In calculating a hospital's average salaries plus wage-related 
costs, including all GME and CRNA costs, we subtracted from Line 1 
(total salaries) the Part B salaries reported on Lines 3 and 5, home 
office salaries reported on Line 7, and excluded salaries reported on 
Lines 8 and 8.01 (that is, direct salaries attributable to skilled 
nursing facility services, home health services, and other subprovider 
components not

[[Page 39864]]

subject to the inpatient prospective payment system). We also 
subtracted from Line 1 the salaries for which no hours were reported on 
Lines 2, 4, and 6. To determine total salaries plus wage-related costs, 
we added to the net hospital salaries the costs of contract labor for 
direct patient care, certain top management, pharmacy, laboratory, and 
physician Part A services (Lines 9, 9.01, 9.02, 10, and 10.01), home 
office salaries and wage-related costs reported by the hospital on 
Lines 11, 12, and 12.01, and nonexcluded area wage-related costs (Lines 
13, 14, 16, 18, 18.01, and 20).
    We note that contract labor and home office salaries for which no 
corresponding hours are reported were not included. In addition, wage-
related costs for specific categories of employees (Lines 16, 18, 
18.01, and 20) are excluded if no corresponding salaries are reported 
for those employees (Lines 2, 4, 4.01, and 6, respectively).
    We then calculated a hospital's salaries plus wage-related costs by 
subtracting from total salaries the salaries plus wage-related costs 
for teaching physicians, Lines (4.01, 10.01, 12.01, and 18.01), Part A 
CRNAs (Lines 2 and 16), and residents (Lines 6 and 20).
    Step 3--Hours--With the exception of wage-related costs, for which 
there are no associated hours, we computed total hours using the same 
methods as described for salaries in Step 2.
    Step 4--For each hospital reporting both total overhead salaries 
and total overhead hours greater than zero, we then allocated overhead 
costs to areas of the hospital excluded from the wage index 
calculation. First, we determined the ratio of excluded area hours (sum 
of Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours 
(Line 1 minus the sum of Part II, Lines 3, 5, 7, and Part III, Line 13 
of Worksheet S-3). We then computed the amounts of overhead salaries 
and hours to be allocated to excluded areas by multiplying the above 
ratio by the total overhead salaries and hours reported on Line 13 of 
Worksheet S-3, Part III. Next, we computed the amounts of overhead 
wage-related costs to be allocated to excluded areas using three steps: 
(1) We determined the ratio of overhead hours (Part III, Line 13) to 
revised hours (Line 1 minus the sum of Lines 3, 5, and 7); (2) we 
computed overhead wage-related costs by multiplying the overhead hours 
ratio by wage-related costs reported on Part II, Lines 13, 14, 16, 18, 
18.01, and 20; and (3) we multiplied the computed overhead wage-related 
costs by the above excluded area hours ratio. Finally, we subtracted 
the computed overhead salaries, wage-related costs, and hours 
associated with excluded areas from the total salaries (plus wage-
related costs) and hours derived in Steps 2 and 3. Using the above 
method for computing overhead salaries, wage-related costs, and hours 
to allocate to excluded areas, we also computed these costs excluding 
all costs associated with GME and CRNAs (Lines 2, 4.01, 6, 10.01, 
12.01, and 18.01).
    Step 5--For each hospital, we adjusted the total salaries plus 
wage-related costs to a common period to determine total adjusted 
salaries plus wage-related costs. To make the wage adjustment, we 
estimated the percentage change in the employment cost index (ECI) for 
compensation for each 30-day increment from October 14, 1997 through 
April 15, 1999 for private industry hospital workers from the Bureau of 
Labor Statistics' Compensation and Working Conditions. We use the ECI 
because it reflects the price increase associated with total 
compensation (salaries plus fringes) rather than just the increase in 
salaries. In addition, the ECI includes managers as well as other 
hospital workers. This methodology to compute the monthly update 
factors uses actual quarterly ECI data and assures that the update 
factors match the actual quarterly and annual percent changes. The 
factors used to adjust the hospital's data were based on the midpoint 
of the cost reporting period, as indicated below.

                    Midpoint of Cost Reporting Period
------------------------------------------------------------------------
         After                    Before            Adjustment  factor
------------------------------------------------------------------------
         10/14/97                 11/15/97                  1.03822
         11/14/97                 12/15/97                  1.03561
         12/14/97                 01/15/98                  1.03292
         01/14/98                 02/15/98                  1.03048
         02/14/98                 03/15/98                  1.02828
         03/14/98                 04/15/98                  1.02621
         04/14/98                 05/15/98                  1.02411
         05/14/98                 06/15/98                  1.02200
         06/14/98                 07/15/98                  1.01973
         07/14/98                 08/15/98                  1.01714
         08/14/98                 09/15/98                  1.01424
         09/14/98                 10/15/98                  1.01137
         10/14/98                 11/15/98                  1.00885
         11/14/98                 12/15/98                  1.00669
         12/14/98                 01/15/99                  1.00462
         01/14/99                 02/15/99                  1.00239
         02/14/99                 03/15/99                  1.00000
         03/14/99                 04/15/99                  0.99746
------------------------------------------------------------------------

    For example, the midpoint of a cost reporting period beginning 
January 1, 1998 and ending December 31, 1998 is June 30, 1998. An 
adjustment factor of 1.01973 would be applied to the wages of a 
hospital with such a cost reporting period. In addition, for the data 
for any cost reporting period that began in FY 1998 and covered a 
period of less than 360 days or more than 370 days, we annualized the 
data to reflect a 1-year cost report. Annualization is accomplished by 
dividing the data by the number of days in the cost report and then 
multiplying the results by 365.
    Step 6--Each hospital was assigned to its appropriate urban or 
rural labor market area before any reclassifications under section 
1886(d)(8)(B) or section 1886(d)(10) of the Act. Within each urban or 
rural labor market area, we added the total adjusted salaries plus 
wage-related costs obtained in Step 5 (with and without GME and CRNA 
costs) for all hospitals in that area to determine the total adjusted 
salaries plus wage-related costs for the labor market area.
    Step 7--We divided the total adjusted salaries plus wage-related 
costs obtained under both methods in Step 6 by the sum of the 
corresponding total hours (from Step 4) for all hospitals in each labor 
market area to determine an average hourly wage for the area.
    Because the FY 2002 wage index is based on a blend of average 
hourly wages, we then added 40 percent of the average hourly wage 
calculated without removing GME and CRNA costs, and 60 percent of the 
average hourly wage calculated with these costs excluded.
    Step 8--We added the total adjusted salaries plus wage-related 
costs obtained in Step 5 for all hospitals in the nation and then 
divided the sum by the national sum of total hours from Step 4 to 
arrive at a national average hourly wage (using the same blending 
methodology described in Step 7). Using the data as described above, 
the national average hourly wage is $22.3096.
    Step 9--For each urban or rural labor market area, we calculated 
the hospital wage index value by dividing the area average hourly wage 
obtained in Step 7 by the national average hourly wage computed in Step 
8.
    Step 10--Following the process set forth above, we developed a 
separate Puerto Rico-specific wage index for purposes of adjusting the 
Puerto Rico standardized amounts. (The national Puerto Rico 
standardized amount is adjusted by a wage index calculated for all 
Puerto Rico labor market areas based on the national average hourly 
wage as described above.) We added the total adjusted salaries plus 
wage-related costs (as calculated in Step 5) for all hospitals in 
Puerto Rico and divided the sum by the total hours for Puerto Rico (as 
calculated in Step 4) to arrive at an overall average hourly wage of 
$10.7529 for Puerto Rico. For each labor market area in Puerto Rico, we 
calculated the

[[Page 39865]]

Puerto Rico-specific wage index value by dividing the area average 
hourly wage (as calculated in Step 7) by the overall Puerto Rico 
average hourly wage.
    Step 11--Section 4410 of Public Law 105-33 provides that, for 
discharges on or after October 1, 1997, the area wage index applicable 
to any hospital that is located in an urban area may not be less than 
the area wage index applicable to hospitals located in rural areas in 
that State. Furthermore, this wage index floor is to be implemented in 
such a manner as to ensure that aggregate prospective payment system 
payments are not greater or less than those that would have been made 
in the year if this section did not apply. For FY 2002, this change 
affects 217 hospitals in 40 MSAs. The MSAs affected by this provision 
are identified in Table 4A by a footnote.

F. Revisions to the Wage Index Based on Hospital Redesignation

    Under section 1886(d)(8)(B) of the Act, hospitals in certain rural 
counties adjacent to one or more MSAs are considered to be located in 
one of the adjacent MSAs if certain standards are met. Under section 
1886(d)(10) of the Act, the Medicare Geographic Classification Review 
Board (MGCRB) considers applications by hospitals for geographic 
reclassification for purposes of payment under the prospective payment 
system.
1. Provisions of Public Law 106-554
    Section 304 of Public Law 106-554 made changes to several 
provisions of section 1886(d)(10) of the Act relating to hospital 
reclassifications and the wage index:
     Section 304(a) amended section 1886(d)(10)(D) of the Act 
by adding a clause (v) to provide that, beginning with FY 2001, an 
MGCRB decision on a hospital reclassification for purposes of the wage 
index is effective for 3 years, unless the hospital elects to terminate 
the reclassification. Section 304(a) also provides that the MGCRB must 
use the 3 most recent years' average hourly wage data in evaluating a 
hospital's reclassification application for FY 2003 and any succeeding 
fiscal year (section 1886(d)(10)(D)(vi) of the Act).
     Section 304(b) provides that, by October 1, 2001, the 
Secretary must establish a mechanism under which a statewide entity may 
apply to have all of the geographic areas in the State treated as a 
single geographic area for purposes of computing and applying a single 
wage index, for reclassifications beginning in FY 2003. Section 304(b) 
further requires that if the Secretary applies a statewide wage index 
to a State, an application under section 1886(d)(10) of the Act by an 
individual hospital in that State would not be considered.
    We address our policy proposals relating to implementation of these 
three provisions of sections 304(a) and (b) of Public Law 106-554 in 
section IV.G. of this final rule. The following discussion of the 
revisions to the wage index based on hospital redesignations reflects 
those policies.
2. Effects of Reclassification
    The methodology for determining the wage index values for 
redesignated hospitals is applied jointly to the hospitals located in 
those rural counties that were deemed urban under section 1886(d)(8)(B) 
of the Act and those hospitals that were reclassified as a result of 
the MGCRB decisions under section 1886(d)(10) of the Act. Section 
1886(d)(8)(C) of the Act provides that the application of the wage 
index to redesignated hospitals is dependent on the hypothetical impact 
that the wage data from these hospitals would have on the wage index 
value for the area to which they have been redesignated. Therefore, as 
provided in section 1886(d)(8)(C) of the Act, the wage index values 
were determined by considering the following:
     If including the wage data for the redesignated hospitals 
would reduce the wage index value for the area to which the hospitals 
are redesignated by 1 percentage point or less, the area wage index 
value determined exclusive of the wage data for the redesignated 
hospitals applies to the redesignated hospitals.
     If including the wage data for the redesignated hospitals 
reduces the wage index value for the area to which the hospitals are 
redesignated by more than 1 percentage point, the area wage index 
determined inclusive of the wage data for the redesignated hospitals 
(the combined wage index value) applies to the redesignated hospitals.
     If including the wage data for the redesignated hospitals 
increases the wage index value for the area to which the hospitals are 
redesignated, both the area and the redesignated hospitals receive the 
combined wage index value.
     The wage index value for a redesignated urban or rural 
hospital cannot be reduced below the wage index value for the rural 
areas of the State in which the hospital is located.
     Rural areas whose wage index values would be reduced by 
excluding the wage data for hospitals that have been redesignated to 
another area continue to have their wage index values calculated as if 
no redesignation had occurred.
     Rural areas whose wage index values increase as a result 
of excluding the wage data for the hospitals that have been 
redesignated to another area have their wage index values calculated 
exclusive of the wage data of the redesignated hospitals.
     Currently, the wage index value for an urban area is 
calculated exclusive of the wage data for hospitals that have been 
reclassified to another area.
    For the FY 2002 wage index, we include the wage data for a 
reclassified urban hospital in both the area to which it is 
reclassified and the MSA where the hospital is physically located. We 
believe this improves consistency and predictability in hospital 
reclassification and wage indexes, as well as alleviates the 
fluctuations in the wage indexes due to reclassifications. For example, 
hospitals applying to reclassify into another area will know which 
hospitals' data will be included in calculating the wage index, because 
even if some hospitals in the area are reclassified, their data will be 
included in the calculation of the wage index of the area where they 
are geographically located. Also, in some cases, excluding the data of 
hospitals reclassified to another MSA could have a large downward 
impact on the wage index of the MSA in which the hospital is physically 
located. The negative impact of removing the data of the reclassified 
hospitals from the wage index calculation could lead to large wage 
disparities between the reclassified hospitals and other hospitals in 
the MSA, as the remaining hospitals would receive reduced payments due 
to a lower wage index. Our approach is to promote consistency and 
simplify our rules with respect to how we construct the wage indexes of 
rural and urban areas. As noted above, in the case of rural hospitals 
redesignated to another area, the wage index of the rural area where 
the hospitals are geographically located is calculated by including the 
wage data of the redesignated hospitals (unless doing so would result 
in a lower wage index).
    Finally, we note that the Medicare Payment Advisory Commission 
(MedPAC), in its March 2001 ``Report to the Congress: Medicare Payment 
Policy,'' recommended this policy (p. 82). (Section VII. of this 
preamble includes a discussion of MedPAC's recommendations and our 
responses.) To illustrate the potential negative impact on hospitals in 
an area where reclassifications of some hospitals to another area 
results in a decline in the wage index after the reclassified hospitals 
are excluded from the wage

[[Page 39866]]

index calculation, MedPAC points out that hospitals in several MSAs 
have organized to pay qualifying hospitals not to reclassify. Our 
policy change in this final rule removes this distorted incentive.
    Comment: One commenter had some concerns about the reclassification 
of rural hospitals. This commenter had two points. The first point was 
that rural hospitals that seek reclassification to urban areas and end 
up ``empty'' because all the urban hospitals have successfully sought 
reclassification elsewhere continue to be disadvantaged because the 
rural hospitals continue to compete with the urban hospitals in that 
area, but those urban hospitals are receiving even higher payments, 
while the rural hospitals are not receiving the same payments. The 
commenter believed that the solution to this dilemma is to allow the 
rural hospitals that seek reclassification to an ``empty'' MSA to 
receive the same wage index as the urban hospitals that were able to 
reclassify out of that MSA, essentially reclassifying both the urban 
hospitals and the proximate rural hospitals to the same area. One other 
commenter made this same point about urban hospitals.
    The commenter's second point was that, periodically, based on 
updated census data, new MSAs appear. Sometimes, a rural hospital 
seeking reclassification to the nearest MSA or rural area is 
disadvantaged when this occurs because reclassification to the new MSA 
does not afford the rural hospital the same advantages as 
reclassification to the MSA to which it formerly sought 
reclassification, but now is not the closest MSA. The commenter wrote 
that rural hospitals previously qualified for geographic 
reclassification to an MSA should retain the option to reclassify to 
that MSA despite the fact that a closer MSA is created.
    Response: First, both rural and, for FY 2002, urban hospitals are 
advantaged by the fact that we hold all areas harmless when calculating 
the wage index for hospitals reclassifying into both MSAs and rural 
areas. While we understand the commenter's point about its competitors, 
we do not believe that this justifies a ``piggyback'' effect for 
reclassification purposes wherein either rural or urban hospitals that 
obtain reclassification into an empty MSA should then be reclassified 
again to an area to which these hospitals are not proximate. Since a 
hospital in this type of situation could not obtain reclassification on 
its own to the area to which the hospitals that have vacated the MSA 
have reclassified, we do not believe that it would be appropriate to 
reclassify them based on the reclassification of another hospital.
    Second, a hospital that is not subject to the proximity criteria 
because it has a special status as either a rural referral center or a 
SCH already has an advantage over other reclassifying hospitals in that 
it can utilize a larger radius in seeking reclassification 
opportunities (under Sec. 412.230(a)(3)). Rural referral centers and 
SCHs may also reclassify to any MSA to which they qualify under 
Sec. 412.230(b). We believe these criteria provide adequate opportunity 
for rural referral centers and SCHs to reclassify.
    Comment: Commenters generally supported our proposal to include the 
wage data for a reclassified urban hospital in both the area to which 
it is reclassified and the MSA where the hospital is physically 
located. The commenters expressed that this would provide more 
stability in the calculation of the wage index, allowing them to plan 
their budgets from year-to-year with more predictability.
    We did not receive any negative comments on this proposal; however, 
we did receive one additional comment that encouraged us to extend the 
hold harmless provision to a further degree. This commenter believed 
that both rural and urban hospitals should benefit from the same hold-
harmless policy. In other words, an urban hospital's wage data should 
be included in the area in which it is physically located if it 
benefits the area. However, The commenter further stated that, on the 
other hand, if it benefits the area to exclude that hospital's wage 
data in the event the hospital successfully seeks reclassification for 
the wage index to another area, then the hospital's data should be 
excluded. The commenter believed that some urban areas may be harmed by 
retaining the wage data of urban hospitals that are reclassifying out 
of those areas.
    Response: We appreciate the commenters' support of our proposal to 
retain an urban hospital's wage data in the area in which it is 
physically located, even if that hospital successfully seeks 
reclassification to another area. As we proposed in the proposed rule, 
in this final rule we are calculating the wage index for urban areas 
effective for FY 2002 payments by including the wage data for a 
reclassified urban hospital in both the area to which it is 
reclassified and the MSA where the hospital is physically located.
    In reference to the commenter who believed that we should apply the 
same hold-harmless policy to urban hospitals as we do to rural 
hospitals, we note that the rural hold-harmless policy (as described 
above) is dictated by section 1886(d)(8)(C)(iii) of the Act. We believe 
that hospitals continue to compete for services with the hospitals that 
are grouped with them in their respective MSAs. Therefore, it would be 
appropriate to continue to calculate the wage index for those areas as 
if those hospitals had not reclassified to another area. As a result, 
we intend to implement our policy to hold urban areas harmless to the 
extent that the wages of the hospitals that are physically located 
within urban areas will continue to be used in the compilation of the 
wage index whether or not these hospitals successfully seek 
reclassification elsewhere.
    Comment: Several commenters expressed interest in utilizing the 
occupational mix data to apply for reclassification for the wage index. 
These commenters pointed out that, at one time, hospitals did have the 
option to use occupational mix data to seek reclassification for the 
wage index as those data were made available by the AHA. In addition to 
the other applicable criteria for reclassification, a hospital that 
applied for reclassification for the wage index using this criterion 
was required to show that its average hourly wage, based on 
occupational mix data, was 90 percent of the area to which it sought 
reclassification.
    Response: Prior to requests for reclassification effective during 
FY 1999, a hospital could be reclassified for the wage index by showing 
that its average hourly wage weighted for occupational categories was 
at least 90 percent of the average hourly wage of the hospitals in the 
area to which it sought reclassification (in addition to the other 
applicable criteria for reclassification). Occupational mix data were 
available from the AHA; however, the AHA stopped collecting the data in 
1993. Therefore, because there was no other suitable source of 
occupational mix data for hospitals to use, we eliminated the option 
for using this data effective with reclassification requests for FY 
1999 (62 FR 45988).
    Section 304(c) of Public Law 106-554 requires that the Secretary 
must provide for the collection of data every 3 years on the 
occupational mix of employees for each short-term, acute care hospital 
participating in the Medicare program, in order to construct an 
occupational mix adjustment to the wage index. These data are to be 
collected by September 30, 2003. Section 304(c) also requires that the 
data are to be applied in the wage index by October 1, 2004. At that 
point, the data will be incorporated into a hospital's average

[[Page 39867]]

hourly wages. Therefore, the occupational mix data will be reflected in 
hospital reclassifications for the wage index as it is incorporated 
into the wage index data. In addition, as soon as viable occupational 
mix data become available, we will consider providing hospitals with 
the opportunity to use it to support their reclassification requests.
    The wage index values for FY 2002 are shown in Tables 4A, 4B, 4C, 
and 4F in the Addendum to this final rule. Hospitals that are 
redesignated should use the wage index values shown in Table 4C. Areas 
in Table 4C may have more than one wage index value because the wage 
index value for a redesignated urban or rural hospital cannot be 
reduced below the wage index value for the rural areas of the State in 
which the hospital is located. When the wage index value of the area to 
which a hospital is redesignated is lower than the wage index value for 
the rural areas of the State in which the hospital is located, the 
redesignated hospital receives the higher wage index value; that is, 
the wage index value for the rural areas of the State in which it is 
located, rather than the wage index value otherwise applicable to the 
redesignated hospitals.
    As mentioned earlier, section 304(a) of Public Law 106-554 amended 
section 1886(d)(10)(D) of the Act by adding a new clause (v) to provide 
that a reclassification of a hospital by the MGCRB for purposes of the 
wage index is effective for 3 years (instead of 1 year) unless, under 
procedures established by the Secretary, the hospital elects to 
terminate the reclassification before the end of the 3-year period. 
Section 304(a) of Public Law 106-554 also amended section 
1886(d)(10)(D) of the Act to specify that, for applications for 
reclassification for the wage index for FYs 2003 and later, the MGCRB 
must base any comparison of the average hourly wage of the hospital 
with the average hourly wage for hospitals in the area in which it is 
located and the area to which it seeks reclassification, using data 
from the most recently published hospital wage survey (as of the date 
of the hospital's application), as well as data from each of the two 
immediately preceding surveys. (Our policies in this final rule to 
incorporate the provisions of section 304(a) of Public Law 106-554 in 
the regulations are addressed in section IV.G. of this final rule).
    Consistent with the section 304(a) amendment, Tables 3A and 3B list 
the 3-year average hourly wage for each labor market area before the 
redesignation of hospitals, based on FY 1996, 1997, and 1998 wage data. 
Table 3A lists these data for urban areas and Table 3B lists these data 
for rural areas. In addition, Table 2 in the Addendum to this final 
rule includes the adjusted average hourly wage for each hospital from 
the FY 1996 and FY 1997 cost reporting periods, as well as the FY 1998 
period used to calculate the FY 2002 wage index. Table 2 also shows the 
3-year average that the MGCRB will use to evaluate a hospital's 
application for reclassification for FY 2003 (unless that average 
hourly wage is later revised in accordance with Sec. 412.63(w)(2)). The 
3-year averages are calculated by dividing the sum of the dollars 
(adjusted to a common reporting period using the method described 
previously in this section) across all 3 years, by the sum of the 
hours. If a hospital is missing data for any of the previous years, its 
average hourly wage for the 3-year period is calculated based on the 
data available during that period.
    Applications for FY 2003 reclassifications are due to the MGCRB by 
September 4, 2001. (We note that, as of May 21, 2001, the new location 
and mailing address of the MGCRB and the Provider Reimbursement Review 
Board (PRRB) is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 
21244-2670. Also, please specify whether the mail is intended for the 
MGCRB or the PRRB.)
    We indicated in the proposed rule that, at the time the proposed 
wage index was constructed, the MGCRB had completed its review of FY 
2002 reclassification requests. The final FY 2002 wage index values 
incorporate all 643 hospitals redesignated for purposes of the wage 
index (hospitals redesignated under section 1886(d)(8)(B) or section 
1886(d)(10) of the Act for FY 2002. Since publication of the May 4 
proposed rule, the number of reclassifications has changed because some 
MGCRB decisions were still under review by the Administrator and 
because some hospitals decided to withdraw their requests for 
reclassification.
    Changes to the wage index that resulted from withdrawals of 
requests for reclassification, wage index corrections, appeals, and the 
Administrator's review process have been incorporated into the wage 
index values published in this final rule. The changes may affect not 
only the wage index value for specific geographic areas, but also the 
wage index value redesignated hospitals receive; that is, whether they 
receive the wage index value for the area to which they are 
redesignated, or a wage index value that includes the data for both the 
hospitals already in the area and the redesignated hospitals. Further, 
the wage index value for the area from which the hospitals are 
redesignated may be affected.
    Under Sec. 412.273, hospitals that have been reclassified by the 
MGCRB were permitted to withdraw their applications within 45 days of 
the publication of the May 4, 2001 proposed rule. The request for 
withdrawal of an application for reclassification that would be 
effective in FY 2002 had to be received by the MGCRB by June 18, 2001. 
A hospital that requested to withdraw its application may not later 
request that the MGCRB decision be reinstated.
    In addition, because the 3-year effect of the amendment made by 
section 304(a) of Public Law 106-554 is applicable to reclassifications 
for FY 2001 (which had already taken place prior to the date of 
enactment of Public Law 106-554) and because the application process 
for reclassification for FY 2002 had already been completed by the date 
of enactment, we are deeming hospitals that are reclassified for 
purposes of the wage index to one area for FY 2001 and are reclassified 
for purposes of the wage index or the standardized amount to another 
area for FY 2002 to be reclassified to the area for which they applied 
for FY 2002, unless they elected to receive the wage index 
reclassification they were granted for FY 2001. Consistent with our 
application withdrawal procedures under Sec. 412.273, we allowed 
hospitals that wished to receive, for FY 2002, the reclassification 
they were granted for FY 2001, to withdraw their applications by June 
18, 2001 also.
    Comment: Two commenters requested us to continue publishing the 
case-mix index because it assists hospitals in monitoring possible 
referral center qualifying status and in preparing applications for 
reclassification to use another area's standardized amount. (We also 
received numerous telephone calls with this request.)
    Response: Prior to this year, the case-mix index was published in 
Table 3C. This index shows the average DRG relative weight for 
discharges from a prior fiscal year. Due to the requirement to publish 
so much additional average hourly wage data in Tables 2, 3A, and 3B, we 
stopped publishing the case-mix index beginning with the May 4, 2001 
proposed rule.
    In light of public comments and in balancing the requirements for 
additional publication of average hourly wage data, we will resume 
publishing the case-mix index, but not in the Federal Register. 
Beginning with the publication date of this final rule, we will make 
the case-mix index for FY 2000 and future fiscal years available on

[[Page 39868]]

the internet at: http://www.hcfa.gov/medicare/ippsmain.htm. We intend 
to update the case-mix index at this website to coincide with the 
publication of the annual proposed and final rules.
3. Statewide Wage Index
    As stated earlier, section 304(b) of Public Law 106-554 requires 
the Secretary to establish, by October 1, 2001, a process (based on the 
voluntary process utilized by the Secretary under section 1848 of the 
Act) under which an appropriate statewide entity may apply to have all 
the geographic areas in the State treated as a single geographic area 
for purposes of computing and applying a single wage index, beginning 
in FY 2003. Section 304(b) further requires that, if the Secretary 
applies a statewide wage index to an area, an application by an 
individual hospital in that area would not be considered. We believe 
the reference to the voluntary process utilized by the Secretary under 
section 1848 of the Act refers to the process whereby we allow a State 
containing multiple physician fee schedule payment areas (and thus 
multiple geographic adjustment factors) to voluntarily convert to a 
single statewide payment area with a single geographic adjustment 
factor (see Sec. 414.4(b), as discussed in the June 24, 1994 Federal 
Register (59 FR 32759).
    Section IV.G. of this final rule contains our policy for 
implementing the provisions of section 304(b) in regulations. We are 
providing that hospitals that seek a statewide geographic 
reclassification under the amendments made by section 304(b) of Public 
Law 106-554 must apply to the MGCRB with the same deadlines as other 
hospitals. An approved application by the MGCRB will mean that the data 
of all the hospitals in the State will be used in computing and 
applying the wage index for that State. We are providing that the 
statewide wage index is applicable for 3 years from the date of 
approval or until all of the participating hospitals terminate their 
approved statewide wage index reclassification (effective with the next 
full fiscal year after their termination request), whichever occurs 
first.
4. Section 402 of Public Law 106-113
    Beginning October 1, 1988, section 1886(d)(8)(B) of the Act 
required us to treat a hospital located in a rural county adjacent to 
one or more urban areas as being located in the MSA to which the 
greatest number of workers in the county commute, if the rural county 
would otherwise be considered part of an urban area under the standards 
published in the Federal Register on January 3, 1980 (45 FR 956) for 
designating MSAs (and for designating NECMAs), and if the commuting 
rates used in determining outlying counties (or, for New England, 
similar recognized areas) were determined on the basis of the aggregate 
number of resident workers who commute to (and, if applicable under the 
standards, from) the central county or counties of all contiguous MSAs 
(or NECMAs)). Hospitals that met the criteria using the January 3, 1980 
version of these OMB standards were deemed urban for purposes of the 
standardized amounts and for purposes of assigning the wage index.
    During FY 1994, we incorporated the revised MSA definitions based 
on 1990 census population data. As a result, some counties that 
previously were treated as an adjacent county under section 
1886(d)(8)(B) of the Act officially became part of certain MSAs. 
However, as specified in the Act, we continued to utilize the January 
3, 1980 standards. For FY 2000, there were 27 hospitals in 22 counties 
affected by this provision.
    On March 30, 1990, OMB issued revised 1990 standards (55 FR 12154). 
There has been an increasing amount of interest by the hospital 
industry in using the 1990 standards as opposed to the 1980 standards 
to determine which hospitals qualify under the provisions set forth in 
section 1886(d)(8)(B) of the Act. Section 402 of Public Law 106-113 
provides that, with respect to FYs 2001 and 2002, a hospital may elect 
to have the 1990 standards applied to it for purposes of section 
1886(d)(8)(B) and that, beginning with FY 2003, hospitals will be 
required to use the standards published in the Federal Register by the 
Director of OMB based on the most recent decennial census.
    We worked with staff of the Population Distribution Branch within 
the Population Division of the Census Bureau to compile a list of 
hospitals that meet the March 30, 1990 standards using 1990 census 
population data and information prepared for the Metropolitan Area 
Standards Review Project. The conditions that must be met for a 
hospital located in a rural county adjacent to one or more urban areas 
to be treated as being located in the urban area to which the greatest 
number of workers in the rural county commute are as follows:
     The rural county would otherwise be considered part of an 
MSA but for the fact that the rural county does not meet the standard 
established by OMB relating to the commuting rate of workers between 
the county and the central county or counties of any adjacent MSA.
     The county would meet the commuting standard if commuting 
to (and where applicable, from) the central county or central counties 
of all adjacent MSAs or NECMAs (rather than to just one) were 
considered.
    A county meeting the above commuting standards must also meet the 
other standards established by OMB for inclusion in an MSA as an 
outlying county. In order to meet these requirements, the rural county 
must have a degree of ``metropolitan character.'' ``Metropolitan 
character'' is established by meeting one of the following OMB 
standards, which were published in the Federal Register on March 30, 
1990:
    a. At least 50 percent of the employed workers residing in the 
county commute to the central county/counties, and either--
     The population density of the county is at least 25 
persons per square mile; or
     At least 10 percent of the population, or at least 5,000 
persons, lives in the qualifier urbanized area(s).
    b. From 40 to 50 percent of the employed workers commute to the 
central county/counties, and either--
     The population density is at least 35 persons per square 
mile; or
     At least 10 percent of the population, or at least 5,000 
persons, lives in the qualifier urbanized area(s).
    c. From 25 to 40 percent of the employed workers commute to the 
central county/counties and either the population density of the county 
is at least 50 persons per square mile, or any two of the following 
conditions exist:
     Population density is at least 35 persons per square mile.
     At least 35 percent of the population is urban.
     At least 10 percent of the population, or at least 5,000 
persons, lives in the qualifier urbanizer area(s).
    d. From 15 to 25 percent of the employed workers commute to the 
central county/counties, the population density of the county is at 
least 50 persons per square mile, and any two of the following 
conditions also exist:
     Population density is at least 60 persons per square mile.
     At least 35 percent of the population is urban.
     Population growth between the last two decennial censuses 
is at least 20 percent.
     At least 10 percent of the population, or at least 5,000 
persons, lives in the qualifier urbanized area(s).
    Also accepted as meeting this commuting requirement under item d. 
are:

[[Page 39869]]

     The number of persons working in the county who live in 
the central county/counties is equal to at least 15 percent of the 
number of employed workers living in the county; or
     The sum of the number of workers commuting to and from the 
central county/counties is equal to at least 20 percent of the number 
of employed workers living in the county.
    e. From 15 to 25 percent of the employed workers commute to the 
central county/counties, the population density of the county is less 
than 50 persons per square mile, and any two of the following 
conditions also exist:
     At least 35 percent of the population is urban.
     Population growth between the last two decennial censuses 
is at least 20 percent.
     At least 10 percent of the population, or at least 5,000 
persons, lives in the qualifier urbanized area(s).
    f. At least 2,500 of the population lives in a central city of the 
MSA located in the qualifier urbanized area(s).
    When we apply the 1990 standards as opposed to 1980 standards, the 
number of qualifying counties increases from 22 to 31. On the basis of 
the evaluation of these data, effective for discharges occurring on or 
after October 1, 2001, hospitals listed in the first column of the 
following table are considered, for purposes of assigning the inpatient 
standardized amount and the wage index, to be located in the 
corresponding urban area in the second column:

----------------------------------------------------------------------------------------------------------------
                Rural county                                                 MSA
----------------------------------------------------------------------------------------------------------------
Chilton, AL................................  Birmingham, AL
Marshall, AL...............................  Huntsville, AL
Talladega, AL..............................  Anniston, AL
Bradford, FL...............................  Jacksonville, FL
Hendry, FL.................................  West Palm Beach-Boca Raton, FL
Putnam, FL.................................  Gainesville, FL
Jackson, GA................................  Athens, GA
Christian, IL..............................  Springfield, IL
Macoupin, IL...............................  St. Louis, MO-IL
Piatt, IL..................................  Champaign-Urbana, IL
Brown, IN..................................  Indianapolis, IN
Carroll, IN................................  Lafayette, IN
Henry, IN..................................  Indianapolis, IN
Jefferson, KS..............................  Topeka, KS
Barry, MI..................................  Kalamazoo-Battle Creek, MI
Cass, MI...................................  Benton Harbor, MI
Ionia, MI..................................  Grand Rapids-Muskegon-Holland, MI
Shiawassee, MI.............................  Flint, MI
Tuscola, MI................................  Saginaw-Bay City-Midland, MI
Caswell, NC................................  Greensboro-Winston Salem-High Point, NC
Greene, NC.................................  Greenville, NC
Harnett, NC................................  Raleigh-Durham-Chapel Hill, NC
Wilson, NC.................................  Rocky Mount, NC
Preble, OH.................................  Dayton-Springfield, OH
Van Wert, OH...............................  Lima, OH
Adams, PA..................................  York, PA
Lawrence, PA...............................  Pittsburgh, PA
Monroe, PA.................................  Newark, NJ
Schuylkill, PA.............................  Reading, PA
Jefferson, WI..............................  Milwaukee-Waukesha, WI
Walworth, WI...............................  Milwaukee-Waukesha, WI
----------------------------------------------------------------------------------------------------------------

    There are 14 counties that meet the qualifying criteria using 1990 
standards that did not meet the criteria using the 1980 standards. 
These 14 counties are:

Chilton, AL
Talladega, AL
Bradford, FL
Hendry, FL
Putnam, FL
Jackson, GA
Piatt, IL
Brown, IN
Carroll, IN
Greene, NC
Wilson, NC
Adams, PA
Monroe, PA
Schuylkill, PA.

    In addition, when we apply the 1980 standards for three of the 
counties, the MSA assigned is different from the MSA that would be 
assigned using the 1990 standards. These counties are as follows:

----------------------------------------------------------------------------------------------------------------
                                        1980 MSA
          Rural county                designation                         1990 MSA designation
----------------------------------------------------------------------------------------------------------------
Ionia, MI.......................  Lansing-East         Grand Rapids-Muskegon-Holland, MI.
                                   Lansing, MI.
Caswell, NC.....................  Danville, VA.......  Greensboro-Winston Salem-High Point, NC.
Harnett, NC.....................  Fayetteville, NC...  Raleigh-Durham-Chapel Hill, NC.
----------------------------------------------------------------------------------------------------------------

    Section 402 of Public Law 106-113 states that hospitals may elect 
to use either the January 3, 1980 standards or the March 30, 1990 
standards for payments during FY 2001 and FY 2002. We are assuming 
hospitals will elect to go to the MSA resulting in the highest payment 
amount accounting for the applicable wage indexes and standardized 
amounts. Based on our analysis, we believe all hospitals in the 
designated rural counties would benefit by being included in the 
respective MSAs shown above. Therefore, we proposed to assign the FY 
2002

[[Page 39870]]

standardized amount and wage index of each respective MSA to the 
affected hospitals. Hospitals electing not to use the 1990 standards 
would be required to notify their fiscal intermediary in writing of 
such election prior to September 1, 2001, in order to allow sufficient 
time to reflect this change in our payment systems.
    We note that five rural counties no longer meet the qualifying 
criteria when we apply the revised OMB standards. These rural counties 
are as follows: Indian River, FL; Mason, IL; Owen, IN; Morrow, OH; and 
Lincoln, WV. For FY 2002, we continue to treat these hospitals as 
attached to an MSA on the basis of the 1980 standards. Beginning FY 
2003, they must meet the 1990 standards to continue to be treated as 
such.
    We stated in the August 1, 2000 final rule that implemented changes 
to the prospective payment system for FY 2001 that we were in the 
process of working with OMB to identify the hospitals that would be 
affected by section 402 of Public Law 106-113 (65 FR 47076). We further 
indicated we would revise payments to hospitals in the affected 
counties as soon as data were available. Now that the affected counties 
have been identified, hospitals in the 14 counties identified above 
will be offered the opportunity to elect this designation, as 
previously described. We will provide further information related to 
this election, including recalculated wage indexes, through a 
forthcoming program memorandum.
    Finally, three hospitals located in counties affected by the 
revised OMB standards also have been reclassified by the MGCRB. The 
affected hospitals are listed below. If the hospitals did not wish to 
be reclassified for FY 2002 based on their new designation as described 
above, they had to follow the procedures described above for requesting 
that their application for reclassification be withdrawn.

------------------------------------------------------------------------
                                                           FY 2002
        Provider No.          1990 MSA Designation    reclassification,
                                                             MSA
------------------------------------------------------------------------
34-0071.....................  Raleigh-Durham-       Fayetteville, NC.
                               Chapel Hill, NC.
34-0124.....................  Raleigh-Durham-       Fayetteville, NC.
                               Chapel Hill, NC.
34-0126.....................  Rocky Mount, NC.....  Raleigh-Durham-
                                                     Chapel Hill, NC
                                                     (wage index only).
------------------------------------------------------------------------

5. Provisions of the August 1, 2000 Interim Final Rule: Sections 
152(a), 153, and 154a) of Public Law 106-113
    In the August 1, 2000 interim final rule with comment period, we 
implemented sections 152(a), 153, and 154(a) of Public Law 106-113. 
These sections contained provisions under which hospitals in certain 
counties are deemed to be located in specified areas for purposes of 
payment under the hospital inpatient prospective payment system, for 
discharges occurring during FY 2000. For payment purposes, hospitals 
under section 152(a) are to be treated as though they were reclassified 
for purposes of both the standardized amount and the wage index. 
Sections 153 and 154(a) did not affect the standardized amount. In the 
interim final rule, we calculated FY 2000 wage indexes for hospitals in 
the affected counties. These wage indexes are listed below. No other 
hospitals' FY 2000 wage indexes were affected, including those 
hospitals in the areas to which these affected hospitals were 
reclassified, as well as nonreclassified hospitals located in the areas 
from which these hospitals were reclassified.
    We also implemented section 152(a), which provided that, for 
purposes of making payments under section 1886(d) of the Act for FY 
2000--
     To hospitals in Iredell County, North Carolina, Iredell 
County was deemed to be located in the Charlotte-Gastonia-Rock Hill, 
North Carolina-South Carolina MSA;
     To hospitals in Orange County, New York, Orange County was 
deemed to be located in the New York, New York MSA;
     To hospitals in Lake County, Indiana and Lee County, 
Illinois, Lake County and Lee County were deemed to be located in the 
Chicago, Illinois MSA;
     To hospitals in Hamilton-Middletown, Ohio, Hamilton-
Middletown was deemed to be located in the Cincinnati, Ohio-Kentucky-
Indiana MSA;
     To hospitals in Brazoria County, Texas, Brazoria County 
was deemed to be located in the Houston, Texas MSA;
     To hospitals in Chittenden County, Vermont, Chittenden 
County was deemed to be located in the Boston-Worcester-Lawrence-
Lowell-Brockton, Massachusetts-New Hampshire MSA.
    In accordance with section 153 of Public Law 106-113, for 
discharges occurring during FY 2000, the Hattiesburg, Mississippi MSA 
wage index was recalculated by including the wage data for Wesley 
Medical Center. In accordance with section 154(a), the Allentown-
Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was recalculated 
by including the wage data for Lehigh Valley Hospital.
    The following table shows the changes to the FY 2000 wage index 
values for the hospitals in the affected counties. Hospitals affected 
by section 152(a) of Public Law 106-113 were also considered 
reclassified for purposes of the standardized amount.

----------------------------------------------------------------------------------------------------------------
                                                                 New MSA (for
                                                                wage index and                   New Georgraphic
                        County or MSA                            standardized   New wage  index     Adjustment
                                                                   amount)                         Factor (GAF)
----------------------------------------------------------------------------------------------------------------
Iredell County, NC...........................................             1520           0.9434           0.9609
Orange County, NY............................................             5600           1.4342           1.2801
Lake County, IN..............................................             1600           1.0750           1.0508
Lee County, IL...............................................             1600           1.0750           1.0508
Hamilton-Middletown, OH......................................             1640           0.9419           0.9598
Brazoria County, TX..........................................             3360           0.9388           0.9577
Chittenden County, VT........................................             1123           1.1359           1.0912
Hattiesburg, MS MSA..........................................             3285           0.7634           0.8312
Allentown-Bethlehem-Easton, PA MSA...........................             0240           1.0228           1.0156
----------------------------------------------------------------------------------------------------------------


[[Page 39871]]

G. Requests for Wage Data Corrections

    In the May 4, 2000 proposed rule, we stated that, to allow 
hospitals time to construct the proposed FY 2002 hospital wage index, 
we would make available in May 2001 a final public data file containing 
the FY 1998 hospital wage data.
    The final wage data file was released on May 4, 2001. As noted 
above in section III.D. of this preamble, this file included hospitals' 
cost report data obtained from Worksheet S-3, Parts II and III of their 
FY 1998 Medicare cost reports. In addition, Table 2 in the Addendum to 
this final rule contains each hospital's adjusted average hourly wage 
used to construct the wage index values for the past 3 years, including 
the FY 1998 data used to construct the final FY 2002 wage index.
    Under revised procedures, hospitals were given an opportunity to 
correct any incorrectly reported FY 1998 wage data on their cost 
reports and submit complete detailed supporting documentation to their 
intermediaries by March 9, 2001. Wage data corrections had to be 
reviewed and verified by the intermediary and transmitted to HCFA on or 
before April 9, 2001. These deadlines were necessary to allow 
sufficient time to review and process the data so that the final wage 
index calculation could be completed for development of the final 
prospective payment rates in this final rule.
    We created the process described above to resolve all substantive 
wage data correction disputes before we finalize the wage data for the 
FY 2002 payment rates. Accordingly, hospitals that did not meet the 
procedural deadlines set forth above were not afforded a later 
opportunity to submit wage data corrections or to dispute the 
intermediary's decision with respect to requested changes. 
Specifically, our policy is that hospitals that do not meet the 
procedural deadlines set forth above will not be permitted to later 
challenge, before the Provider Reimbursement Review Board, HCFA's 
failure to make a requested data revision (See W. A. Foote Memorial 
Hospital v. Shalala, No. 99-CV-75202-DT (E.D. Mich. 2001)).
    As stated above, the final wage data public use file was released 
on May 4, 2001. Hospitals had an opportunity to examine both Table 2 of 
the proposed rule and the May 4 final public use wage data file (which 
reflected revisions to the data used to calculate the values in Table 
2) to verify the data HCFA was using to calculate the wage index. 
Hospitals had until June 4, 2001, to submit requests to correct errors 
in the final wage data due to data entry or tabulation errors by the 
intermediary or HCFA. The correction requests considered at that time 
were limited to errors in the entry or tabulation of the final wage 
data that the hospital could not have known about before the release of 
the final wage data public use file.
    If, after reviewing the May 2001 final data file, a hospital 
believed that its wage data are incorrect due to a fiscal intermediary 
or HCFA error in the entry or tabulation of the final wage data, it was 
provided an opportunity to send a letter to both its fiscal 
intermediary and HCFA, outlining why the hospital believed an error 
exists and provide all supporting information, including dates. These 
requests had to be received by us and the intermediaries no later than 
June 4, 2001.
    Changes to the hospital wage data were made in those very limited 
situations involving an error by the intermediary or HCFA that the 
hospital could not have known about before its review of the final wage 
data file. Specifically, neither the intermediary nor HCFA accepted the 
following types of requests at that stage of the process:
     Requests for wage data corrections that were submitted too 
late to be included in the data transmitted to HCFA on or before April 
9, 2001.
     Requests for correction of errors that were not, but could 
have been, identified during the hospital's review of the February 2001 
wage data file.
     Requests to revisit factual determinations or policy 
interpretations made by the intermediary or HCFA during the wage data 
correction process.
    Verified corrections to the wage index received timely (that is, by 
June 4, 2001) are incorporated into the final wage index in this final 
rule, to be effective October 1, 2001.
    Again, we believe the wage data correction process described above 
provides hospitals with sufficient opportunity to bring errors in their 
wage data to the intermediary's attention. Moreover, because hospitals 
had access to the final wage data by early May 2001, they had the 
opportunity to detect any data entry or tabulation errors made by the 
intermediary or HCFA before the development and publication of the FY 
2002 wage index and its implementation on October 1, 2001. If hospitals 
availed themselves of this opportunity, the wage index implemented on 
October 1 should be accurate. Nevertheless, in the event that errors 
are identified after that date, we retain the right to make midyear 
changes to the wage index under very limited circumstances.
    Specifically, in accordance with Sec. 412.63(w)(2), we may make 
midyear corrections to the wage index only in those limited 
circumstances in which a hospital can show (1) that the intermediary or 
HCFA made an error in tabulating its data; and (2) that the hospital 
could not have known about the error, or did not have an opportunity to 
correct the error, before the beginning of FY 2002 (that is, by the 
June 4, 2001 deadline). As indicated earlier, since a hospital had the 
opportunity to verify its data, and the intermediary notified the 
hospital of any changes, we do not foresee any specific circumstances 
under which midyear corrections would be necessary. However, should a 
midyear correction be necessary, the wage index-change for the affected 
area will be effective prospectively from the date the correction is 
made.

H. Modification of the Process and Timetable for Updating the Wage 
Index

    Although the wage data correction process described above has 
proven successful in the past for ensuring that the wage data used each 
year to calculate the wage indexes are generally reliable and accurate, 
we are concerned about the growing volume of wage data revisions 
initiated by hospitals during February and the first week of March. We 
first discussed this issue in the FY 1998 proposed rule (62 FR 29918). 
At that time, we noted that, in developing the FY 1997 wage index, the 
wage data were revised between the proposed and final rules for more 
than 13 percent of the hospitals (approximately 700 of 5,200). Last 
year, in developing the FY 2001 wage index, the wage data were revised 
between the proposed and final rules for more than 32 percent of the 
hospitals (1,605 of 4,950). This year, in developing the FY 2002 wage 
index, the wage data were revised between the proposed rule and the 
final rule for 30 percent of the hospitals (1,473 of 4,910).
    In the May 4, 2001 proposed rule, we indicated that since hospitals 
are expected to submit complete and accurate cost report data, and 
intermediaries review and request hospitals to correct problematic wage 
data before the data are submitted to HCFA in mid-November, we believed 
there should be limited revisions at this stage of the process. We 
reminded the hospital community that the primary purpose of this file 
is to allow hospitals to verify that we have their correct data on 
file. However, according to information received from the 
intermediaries, these late revisions are frequently due to hospitals' 
lack of responsiveness in providing sufficient information to the 
intermediaries during the desk reviews (that is, during the

[[Page 39872]]

intermediary's review of the hospital's cost report).
    In the proposed rule, we proposed two changes to the wage index 
development process and timetable beginning with the FY 2003 wage 
index. We believed these changes would encourage earlier submissions of 
wage data revisions by hospitals and would allow intermediaries more 
time to address the heavy volume of revisions requested after the 
intermediaries have completed their desk reviews of these data. First, 
we proposed to release the preliminary wage data file by early January 
rather than early February. As with the current preliminary file, the 
January file would include desk reviewed wage data that intermediaries 
submitted to us by November of the previous year and any timely 
revisions we received from intermediaries prior to release of the 
January file. Hospitals would be allowed until early February to submit 
requests for wage data revisions to their intermediaries. Second, 
intermediaries would be allowed approximately 8 weeks from the 
hospitals' deadline for submitting revision requests (that is, until 
early March) to review and transmit revised wage data to us.
    We believed that the proposed revised schedule would improve the 
quality of the wage index by allowing intermediaries more time to 
sufficiently review wage data revisions before the data are submitted 
to us. Further, we believed the proposed revised process would 
encourage hospitals to submit revisions earlier, so the proposed wage 
index, from which hospitals base geographic reclassification decisions, 
is more accurate.
    The timetable for developing the annual update to the wage index is 
as follows (an asterisk indicates no change from prior years):
Mid-November *
    All desk reviews for hospitals wage data are completed and revised 
data transmitted by the fiscal intermediaries to HCRIS.
Early December *
    CMS compiles file of wage data, received by mid-November, and sends 
it to the fiscal intermediaries for verification.
Early January
    Edited wage data are available for release to the public.
Early February
    Deadline for hospitals to request wage data revisions and provide 
adequate documentation to support the request.
April/May *
    Proposed rule published with 60-day comment period and 45-day 
withdrawal deadline for hospitals applying for geographic 
reclassification.
Early April *
    Deadline for the fiscal intermediaries to submit all revisions 
resulting from the hospitals' requests for adjustments (as of early 
February) (and verification of data submitted as of early January).
    Deadline for hospital's to request CMS's intervention in cases 
where the hospital disagrees with the fiscal intermediary's policy 
interpretations pertaining to the allowability of particular costs.
Late April *
    Fiscal intermediaries will alert hospitals to the availability of 
the final wage data file for their review and inform hospitals of the 
June deadline for hospitals to submit correction requests for 
corrections to errors due to CMS or fiscal intermediary mishandling of 
the final wage data.
Early May *
    Release of final wage data public use file on CMS web page and 
through public use files office.
Early June *
    Deadline for hospitals to submit correction requests to both CMS 
and the fiscal intermediaries to correct errors due to CMS or fiscal 
intermediary mishandling of the final wage data.
August 1 *
    Publication of the final rule.
October 1 *
    Effective date of updated wage index.
    Comment: One commenter agreed, in general, with the premise of the 
proposed revised schedule. The commenter recommended that we publish 
the preliminary wage data file in August, using data from the 
hospitals' as-filed cost reports before fiscal intermediaries begin the 
wage index desk reviews. Hospitals would then have until October 1 to 
submit requests, along with supporting documentation, to correct 
errors. The commenter's proposal would give fiscal intermediaries until 
November 30 to complete the desk review and transmit the wage index 
data to us. The commenter believed that implementation of the 
recommended schedule eliminates the fiscal intermediary's duplication 
of effort (that is, reviewing the data a second time when hospitals 
request changes after the desk review, and then resubmitting the data 
to us) that exists in the current process.
    Response: We appreciate the commenter's general support for our 
proposal to revise the wage index schedule, and we will give the 
commenter's recommended process careful consideration in developing 
future updates to the wage index. Having received no other comments 
opposing our proposed schedule, we will implement that schedule, 
beginning with the FY 2003 wage index. We believe that our revised 
schedule is a logical step in the evolution of the wage index 
development process. We will monitor the effectiveness of the revised 
schedule.

IV. Other Decisions and Changes to the Prospective Payment System 
for Inpatient Operating Costs and Graduate Medical Education Costs

A. Sole Community Hospitals (SCHs) (Secs. 412.63, 412.71, 412.72, 
412.73, 412.75, 412.77, and 412.92)

    For the benefit of the reader, in this final rule, we are 
discussing and clarifying many of the rules and policies governing SCHs 
because of the legislative changes that have occurred in recent years. 
It has been several years since the SCH criteria have been published in 
one location. Rather than continue to refer to various Federal Register 
documents and sections of the Code of Federal Regulations, we are 
publishing a detailed discussion of these policies, making further 
changes to incorporate the provisions of sections 213, 302, 303, 304, 
and 311 of Public Law 106-554, and clarifying other related policies.
    Under the hospital inpatient prospective payment system, special 
payment protections are provided to an SCH. Section 1886(d)(5)(D)(iii) 
of the Act defines an SCH as a hospital that, by reason of factors such 
as isolated location, weather conditions, travel conditions, absence of 
other like hospitals (as determined by the Secretary), or historical 
designation by the Secretary as an Essential Access Community Hospital 
(EACH), is the sole source of inpatient hospital services reasonably 
available to Medicare beneficiaries. The regulations that set forth the 
criteria that a hospital must meet to be classified as an SCH are at 
Sec. 412.92. To be classified as an SCH, a hospital must either have 
been designated as an SCH prior to the beginning of the prospective 
payment system on October 1, 1983, and must be located more than 35 
miles from other like hospitals, or the hospital must be

[[Page 39873]]

located in a rural area and meet one of the following requirements:
     It is located more than 35 miles from other like 
hospitals.
     It is located between 25 and 35 miles from other like 
hospitals, and it--

--Serves at least 75 percent of all inpatients, or 75 percent of 
Medicare beneficiary inpatients, within a 35-mile radius or, if larger, 
within its service area; or
--Has fewer than 50 beds and would qualify on the basis of serving 75 
percent of its area s inpatients except that some patients seek 
specialized care unavailable at the hospital.

     It is located between 15 and 25 miles from other like 
hospitals, and because of local topography or extreme weather 
conditions, the other like hospitals are inaccessible for at least 30 
days in each of 2 out of 3 years.
     The travel time between the hospital and the nearest like 
hospital is at least 45 minutes because of distance, posted speed 
limits, and predictable weather conditions.
    Effective with hospital cost reporting periods beginning on or 
after April 1, 1990, section 1886(d)(5)(D)(i) of the Act, as amended by 
section 6003(e) of Public Law 101-239, provides that SCHs are paid 
based on whichever of the following rates yields the greatest aggregate 
payment:
     The Federal rate applicable to the hospital.
     The updated hospital-specific rate based on FY 1982 costs 
per discharge.
     The updated hospital-specific rate based on FY 1987 costs 
per discharge.
    Effective with hospital cost reporting periods beginning on or 
after October 1, 2000, section 1886(b)(3)(I)(i) of the Act, as added by 
section 405 of Public Law 106-113 and amended by section 213 of Public 
Law 106-554, provides for other options, in addition to the three 
bulleted options in the above paragraph, for determining which rate 
would yield the greatest aggregate payment. For discharges for FY 2001 
through FY 2003, these additional optional rates are--
     A phase-in blended rate of the updated hospital-specific 
rate based on FY 1982 costs per discharge and an FY 1996 hospital-
specific rate; or
     A phase-in blended rate of the updated hospital-specific 
rate based on FY 1987 costs per discharge and an FY 1996 hospital-
specific rate.
    For discharges beginning in FY 2004, the additional optional rate 
would be 100 percent of the FY 1996 hospital-specific rate.
    For each cost reporting period, the fiscal intermediary determines 
which of the payment options will yield the highest rate of payment. 
Payments are automatically made at the highest rate using the best data 
available at the time the fiscal intermediary makes the determination. 
However, it may not be possible for the fiscal intermediary to 
determine in advance precisely which of the rates will yield the 
highest payment by year's end. In many instances, it is not possible to 
forecast the outlier payments, the amount of the DSH adjustment, or the 
IME adjustment, all of which are applicable only to payments based on 
the Federal rate. The fiscal intermediary makes a final adjustment at 
the close of the cost reporting period to determine precisely which of 
the payment rates would yield the highest payment to the hospital.
    If a hospital disagrees with the fiscal intermediary's 
determination regarding the final amount of program payment to which it 
is entitled, it has the right to appeal the fiscal intermediary's 
decision in accordance with the procedures set forth in Subpart R of 
Part 405, which concern provider payment determinations and appeals.
    In calculating a hospital-specific rate for an SCH based on its FY 
1996 cost reporting period, we will, to the extent possible, use the 
same methodology that we used to calculate the hospital-specific rate 
based on either the FY 1982 or FY 1987 cost reporting period. That 
methodology is set forth in Secs. 412.71, 412.72, 412.73, 412.75 and 
412.77.
     If a hospital has a cost reporting period ending in FY 
1982, it will be paid a hospital-specific rate based on its FY 1982 
costs; or a hospital-specific rate based on its FY 1987 costs; or a 
hospital-specific rate based on its FY 1996 costs (which, until FY 
2004, would be a blend of the greater of the FY 1982 or FY 1987 costs 
and the FY 1996 costs); or it will be paid based on the Federal rate.
     If a hospital has no cost reporting period ending in FY 
1982, it will be paid a hospital-specific rate based on its FY 1987 
costs; or a hospital-specific rate based on its FY 1996 costs (which, 
until FY 2004, would be a blend of its FY 1987 costs and FY 1996 
costs); or it will be paid based on the Federal rate.
     If a hospital has no cost reporting period ending in 
either FY 1982 or FY 1987, it will be paid based on its FY 1996 costs; 
or it will be paid based on the Federal rate.
     If a hospital has no cost reporting period ending in FY 
1982, FY 1987, or FY 1996, it cannot be paid based on a hospital-
specific rate; it will be paid based on the Federal rate.
     If a hospital was operating during any or all of FY 1982, 
FY 1987, or FY 1996, but, for some reason, the cost report records are 
no longer available, the hospital will be treated as if it had no cost 
report for the applicable period. Section 1886(b)(3)(C) of the Act 
specifies the available periods that may be used.
    For each SCH, the fiscal intermediary will calculate a hospital-
specific rate based on the hospital's FY 1982, FY 1987, or FY 1996 cost 
report as follows:
     Determine the hospital's total allowable Medicare 
inpatient operating cost, as stated on the cost report.
     Divide the total Medicare operating cost by the number of 
Medicare discharges (without adjusting for transfers) in the cost 
reporting period to determine the base period cost per case.
     In order to take into consideration the hospital's 
individual case-mix, the base year cost per case is divided by the 
hospital's case-mix index applicable to the cost reporting period. This 
step is necessary to adjust the hospital's base period cost for case 
mix. This is done to remove the effects of case mix from the base 
period costs per case. Payments using these base period costs are then 
adjusted to reflect the actual case mix during the payment year. A 
hospital's case mix is computed based on its Medicare patient 
discharges subject to DRG-based payment.
    The fiscal intermediary will inform each SCH of its hospital-
specific rate based on its applicable cost reporting period within 180 
days after the start of its cost reporting period.
    (The provisions of section 213 of Public Law 106-554 relating to 
the extension to all SCHs the option to rebase using their FY 1996 
operating costs, for cost reporting periods beginning on or after 
October 1, 2000, were addressed in the June 13, 2001 interim final rule 
with comment period, and are finalized in this final rule.)
    An SCH is also eligible for a payment adjustment if, for reasons 
beyond its control, it experiences a decline in volume of greater than 
5 percent compared to its preceding cost reporting period. This 
adjustment is also available to hospitals that could qualify as SCHs 
but choose not to be paid as SCHs; that is, hospitals that qualify and 
successfully apply to be designated as SCHs but continue to receive 
payments based on the Federal rate. In addition, section 6003(c)(1) of 
Public Law 101-239 deleted the sunset date on the 5-percent volume 
decline adjustment, thus allowing SCHs to receive the adjustment 
indefinitely. The sunset provision was included under section 
1886(d)(5)(C)(ii) of the Act. (Section 6003(c)(1) of Public Law 101-239 
amended that provision and

[[Page 39874]]

redesignated it as section 1886(d)(5)(D) of the Act.)
    In the September 1, 1983, issue of the Federal Register (48 FR 
39781), we stated that any hospital designated as an SCH would retain 
that status until it experienced a change in circumstances. Section 
6003(e)(3) of Public Law 101-239 specifically stated that any hospital 
classified as an SCH as of the date of enactment of Public Law 101-239 
(December 19, 1989), will retain its SCH status even if the hospital 
did not meet the criteria established under section 6003(e)(1) of that 
law. These hospitals are the ``grandfathered'' SCH hospitals. 
Therefore, we have continued to allow hospitals designated as SCHs 
prior to December 19, 1989, to be ``grandfathered'' under current 
criteria.
    In the June 4, 1991 Federal Register, we stated that a hospital's 
special status as an SCH would not be retained in light of the 
hospital's geographic reclassification for purposes of the standardized 
amount. In the event the hospital's reclassification ceases, it must 
reapply for special status and must meet all of the applicable 
qualifying criteria in effect at the time it seeks requalification (56 
FR 25482). However, in the event a ``grandfathered'' SCH was 
successfully reclassified, it would be reinstated as an SCH if its 
reclassification ceased.
    Section 401(a) of Public Law 106-113 established that any 
subsection (d) hospital (section 1886(d) of the Act) located in an 
urban area may be redesignated as being located in a rural area if the 
hospital meets one of several criteria established by the legislation. 
One of these criteria is that the hospital could qualify as an SCH if 
the hospital were located in a rural area. Under this provision, an 
urban hospital that may have been ``grandfathered'' as an SCH could now 
qualify and receive payment as an SCH if it met the criteria of a rural 
SCH instead of as an urban SCH. Given this extension of SCH 
eligibility, we no longer believe it is necessary to extend special 
protection to ``grandfathered'' SCHs that successfully apply for 
geographic reclassification through the MGCRB for the standardized 
amount after their MGCRB reclassification ends. Therefore, a hospital 
that loses its SCH status through a change in circumstances, such as 
reclassification through the MGCRB for the standardized amount, will 
not be reinstated as a SCH unless it can meet all of the SCH qualifying 
criteria in effect at the time it seeks requalification. This 
circumstance falls under the provisions of Secs. 412.92 (b)(3) and 
(b)(5), which state that an approved classification as an SCH remains 
in effect without need for reapproval unless there is a change in the 
circumstances under which the classification was approved. We believe 
that a successful reclassification by the MGCRB fits the definition of 
a change in circumstances.
    Because some hospitals may not have understood the effect 
reclassification would have on their special status, in the May 4 
proposed rule we permitted affected hospitals, under existing 
Sec. 412.273(a), the option to withdraw their applications for 
reclassification for FY 2002, even if the MGCRB had issued a decision, 
by submitting a withdrawal request to the MGCRB within 45 days of 
publication of this proposed rule. Finally, just as a competing 
hospital that closes leaves an opportunity for an existing hospital to 
qualify as an SCH, a new hospital that opens in an area with an 
existing hospital designated as an SCH endangers the SCH status of the 
existing hospital.
    As of October 1, 1997, no designations of hospitals as EACHs can be 
made. The EACHs designated by CMS before October 1, 1997, will continue 
to be paid as SCHs for as long as they comply with the terms, 
conditions, and limitations under which they were designated as EACHs.
    Under Sec. 412.92(b)(2), we define the effective dates for several 
situations in which a hospital gains or gives up SCH status. First, SCH 
status and the associated payment adjustment is effective 30 days after 
CMS's written notification to the SCH. Thus, 30 days after the issuance 
of CMS's notice of approval, the hospital is considered to be an SCH 
and the payment adjustment is applied to discharges occurring on or 
after that date.
    Second, Sec. 412.92(b)(4)(ii) defines the effective date when a 
hospital chooses to give up its SCH status. Our policy has always been 
that an SCH can elect to give up its SCH status at any time by 
submitting a written request to the appropriate CMS regional office 
through its fiscal intermediary. The change to fully national rates 
becomes effective no later than 30 days after the hospital submits its 
request. We believe that the ``no later than 30 days'' policy for the 
effective date for cancelling SCH status is in keeping with the 
prospective nature of the prospective payment system. In addition, the 
30-day timeframe to give up SCH status provides the fiscal 
intermediaries with enough time to alter their automated payment 
systems prospectively, thus avoiding expensive and time-consuming 
reprocessing of claims. The variable timeframe of ``no later than 30 
days from the date of the hospital's request'' also permits the 
regional office, the fiscal intermediary, and the hospital to select a 
mutually agreeable date, for example, at the end of a month, to 
facilitate the change in SCH status. We expect that hospitals will 
anticipate when they wish to give up SCH status and to submit their 
requests in sufficient time to permit the 30-day period for making the 
change.
    In addition, Sec. 412.92(b)(2)(ii) defines the effective date of 
SCH status in the situation where a final and nonappealable 
administrative or judicial decision reverses CMS's denial of SCH status 
to a hospital. In this situation, if the hospital's application was 
submitted on or after October 1, 1983, the effective date will be 30 
days after the date of CMS's original written notification of denial.
    Under Sec. 412.92(b)(2)(iii), we define retroactive approval of SCH 
status. If a hospital is granted retroactive approval of SCH status by 
a final and nonappealable court order or an administrative decision 
under subpart R of part 405 of the regulations, and it wishes its SCH 
status terminated prior to the current date (that is, it wishes to be 
paid as an SCH for a time-limited period, all of which is in the past), 
it must submit written notice to the CMS regional office through its 
fiscal intermediary within 90 days of the court order or the 
administrative decision. This written notice must clearly state that, 
although SCH status was granted retroactively by the court order or by 
the administrative decision, the hospital wants this status terminated 
as of a specific date. If written notice is not received within 90 days 
of the court order or the administrative decision, SCH status will 
continue. Written requests to terminate SCH status that are received 
subsequent to the 90-day period will be effective no later than 30 days 
after the request is submitted, as discussed above.
    Under Sec. 412.92(c)(1), we define mileage. We believe that mileage 
should continue to be measured by the shortest route over improved 
roads maintained by any local, State, or Federal government entity for 
public use. We consider improved roads to include the paved surface up 
to the front entrance of the hospital because this portion of the 
distance is utilized by the public to access the hospital. This 
definition provides consistency with the interpretation of the MGCRB 
when considering hospital reclassification applications. The MGCRB 
measures the distance between the hospital and the county line of the 
area to which it seeks reclassification beginning with the paved area 
outside the front entrance of

[[Page 39875]]

the hospital. This provides a consistent, national definition that is 
easily recognizable for each hospital. Finally, rounding of mileage is 
not permissible. This is also consistent with the MGCRB definition of 
mileage (56 FR 25483). In this final rule, we are revising the 
definition of ``miles'' under Sec. 412.92(c)(1) to state that an 
improved road includes the paved surface up to the front entrance of 
the hospital.
    Under Sec. 412.92(c)(2), we define ``like'' hospital. We consider 
like hospitals to be those hospitals furnishing short-term acute care. 
That is, a hospital may not qualify for an SCH classification on the 
grounds that neighboring hospitals offer specialty services, thereby 
seeking to exclude close-by competitors as like hospitals, in order to 
meet the mileage criteria by measuring to a like hospital that is 
located further away. For example, we believe that competing hospitals 
within a given area may each have their own specialty services, while 
all the facilities continue to be considered short-term acute care 
hospitals. We note that under Sec. 412.92(a)(1)(ii), a hospital with 
fewer than 50 beds may qualify for SCH status under a special provision 
if patients that it would normally serve are seeking care elsewhere due 
to the unavailability of specialty services. This means that, if a 
hospital can prove that the patients from its service area are seeking 
specialty services elsewhere (such as, among others, heart surgery, 
transplants, and burn care), rather than routine care, and, because of 
that fact, that it otherwise would have met the criteria of section 
Sec. 412.92(a)(1)(i), it can qualify as an SCH.
    We note that Sec. 412.92(b)(1)(iii)(A) retains an outdated 
reference to ``hospitals located within a 50 mile radius of the 
hospital.'' With the issuance of the September 1, 1989 Federal Register 
(54 FR 36481, 36482), the 50 mile radius was determined to be 
unreasonable and all references should have been changed to 35 miles in 
accordance with Sec. 412.92(a)(1)(i). In this final rule. we are 
revising the reference to ``a 50 mile radius'' in 
Sec. 412.92(b)(1)(iii)(A) to read ``a 35 mile radius''.
    We note that the travel time and weather conditions criteria set 
forth in Sec. 412.92(a)(3) were discussed in detail in the September 4, 
1990 Federal Register (55 FR 36050 through 36055 and 36162 through 
36163).
    Under Sec. 412.92(a)(1)(i) and (b)(1)(ii), we define the market 
area analysis criteria used to determine SCH status. In the May 4, 2001 
proposed rule, we discussed several points concerning these requests 
for SCH status that we proposed to clarify.
    First, a hospital seeking an SCH designation based on these 
criteria must make its initial request to the fiscal intermediary with 
all the appropriate documents as will be discussed below 
(Sec. 412.92(b)(1)(i)). The fiscal intermediary will make a 
recommendation on the request, based on receipt of all the appropriate 
documentation and its own investigation and analysis, and that 
recommendation will be forwarded to the CMS regional office for another 
level of review and final approval or disapproval. The fiscal 
intermediary would forward its recommendation to the CMS regional 
office located in the hospital's area as opposed to the fiscal 
intermediary's area, if there is a difference in these areas. As 
discussed above, an approval of the request for SCH status will be 
effective 30 days after CMS issues the approval letter. If a 
determination on the request requires the use of data that are 
available at CMS central office only, upon receipt of the fiscal 
intermediary's recommendation, the CMS regional office will forward the 
request and the fiscal intermediary's recommendation to the appropriate 
contact at CMS central office where the determination will be made.
    Second, a hospital must provide patient origin data (the number of 
patients from each zip code from which the hospital draws inpatients) 
for all inpatient discharges to document the boundaries of its service 
area (Sec. 412.92(b)(1)(ii)(A)). Or, the hospital can request that CMS 
develop patient origin data to define its service area based on the 
number of patients from each zip code from which the hospital draws 
Medicare Part A inpatients (Sec. 412.92(b)(1)(iii)). Then, the lowest 
number of zip codes in descending percentage order of Medicare 
inpatients that meets the 75-percent threshold will be used to 
represent the hospital's service area. We note that hospitals cannot 
substitute zip codes elsewhere on the list in order to manipulate the 
service area. (See Howard Young Medical Center, Inc. v. Shalala, 207 
F.3d 437 (7th Cir. 2000).)
    Third, the hospital must provide patient origin data from all other 
hospitals located within a 35-mile radius of it or, if larger, within 
its service area, to document that no more than 25 percent of either 
all of the population or the Medicare beneficiaries residing in the 
hospital's service area and hospitalized for inpatient care were 
admitted to other like hospitals for care (Sec. 412.92(b)(1)(ii)(B)). 
Again, CMS central office can develop patient origin data for other 
hospitals within the requesting hospital's service area if the hospital 
is requesting SCH status based on an examination of Medicare Part A 
inpatient utilization. In either case, the requesting hospital is 
required to submit a comprehensive list of hospitals located within a 
35-mile radius or, if larger, within its service area. This list will 
be checked by both the fiscal intermediary and CMS. Again, a requesting 
hospital cannot argue that a competing hospital should be excluded from 
the service area based on the existence of specialty services at that 
hospital if both hospitals are short-term acute care facilities. 
Distances between all reported hospitals will be checked by both the 
fiscal intermediary and CMS, through electronic geographic mapping 
services (such as Yahoo or Mapquest) or by physically driving the 
distance involved.
    In addition, data will be analyzed based on the year for which the 
hospital requests SCH status. Subsequent hospital mergers or 
terminations will not be taken into consideration in processing the 
request. For example, if a hospital requests SCH status using data for 
FY 1999, and that data show that there is a competing hospital in 
existence that subsequently closed its doors in FY 2000, the data will 
be analyzed with the terminated hospital in existence, unless the 
hospital seeking SCH status applies using later data, such as FY 2001. 
This principle is consistent with how we analyze wage index data. If a 
terminated hospital has a viable cost report for the year of wage data 
that is being analyzed to produce the wage index, its data are included 
as part of the computation.
    We received the following comments on our May 4, 2001 proposed rule 
and the June 13, 2001 interim final rule with comment period:
    Comment: Several commenters were concerned with the following 
issues related to the qualifying criteria for sole community hospitals: 
(1) Utilizing TAC worksheets or other data sources in order to develop 
a base year alternative for a new SCH; (2) determining a service area; 
(3) recognition of hospital mergers and terminations that influence a 
hospital seeking SCH status; (4) including competing hospitals within a 
35-mile radius of the requesting hospital as opposed to a 35-road-mile 
distance; (5) obtaining patient origin data from competing hospitals, 
(6) timeliness of SCH approvals; (7) SCH status for hospitals with 
fewer than 50 beds; (8) CAHs as like hospitals; (9) the effect of wage 
index reclassifications on a hospital's SCH status; and (10) the use of 
affidavits and other certifications in

[[Page 39876]]

verifying time and distance when applying for SCH status.
    Response: We would like to reiterate that in the proposed rule we 
were restating historical and current policy and criteria for SCHs. We 
were not proposing new SCH policies or criteria, or revisions to 
existing policies or criteria. Rather, we were striving to publish 
criteria that has been developed over the past several years in one 
location for the reader's benefit.
    First, we appreciate the input concerning a hospital's access to 
alternative data when a cost report from a prior year may not be 
readily available. We will take this comment into consideration in 
working with the fiscal intermediaries in the future to adjust a SCH's 
payments.
    Second, we believe that, using discharge data available on the 
MedPAR file, we can accurately determine a hospital's service area 
based on the zip codes that contain the highest number of discharges 
for that facility and rank those zip codes accordingly. Several 
commenters suggested that we use patient destination data that are 
available in some States and, also, that we not be concerned if these 
data were not available based on a hospital's cost reporting period. As 
in other aspects of the Medicare program, we must rely on data that are 
consistent, verifiable by the fiscal intermediaries, and nationally 
available so that no one hospital or group of hospitals receives a 
distinct advantage by using an alternative source of data that is not 
widely available. Therefore, we believe that it is appropriate to 
determine the hospital's service area based on Medicare discharges.
    Third, if a hospital chooses to have a merger recognized in its 
request for SCH status, or, likewise, a hospital termination, then it 
is free to wait until its cost report data reflects these changes. 
Then, CMS will consider the data in light of these facts.
    Fourth, we believe it is reasonable to examine a hospital's 
competitors within a 35-mile radius. Most competing hospitals will not 
be at the outer limit of the 35-mile radius, and, if these hospitals 
are not truly competitors, the discharge data will bear out that fact. 
Also, we examine a hospital's service area based on discharges within 
zip code areas, and, often, this will exceed a 35-mile radius. 
Therefore, we believe the 35-mile radius is reasonable.
    Fifth, we realize that obtaining patient origin data from competing 
hospitals may be a difficult proposition, which is why CMS offers to 
provide this information for the requesting hospital in 
Sec. 412.92(b)(1)(iii)(A). CMS' data are based on Medicare discharges.
    Sixth, approvals of SCH status are effective prospectively. There 
are several ways in which a hospital may qualify as a SCH, and fiscal 
intermediaries are required to collect and examine detailed 
documentation which sometimes requires the assistance of our regional 
or central office staff. We appreciate the fact that hospitals are 
concerned that their applications be approved in a timely manner, and 
we will make every effort to work diligently with our contractors as 
well as our regional offices to achieve that goal.
    Seventh, a commenter suggested that we should be more specific when 
defining the criteria under which a hospital with fewer than 50 beds 
could qualify as an SCH at Sec. 412.92(a)(ii). We will take this into 
consideration as we develop further criteria in the future. In the 
meantime, we will continue to work closely with our fiscal 
intermediaries in approving a hospital's SCH status under this 
provision.
    Eighth, we do not consider CAHs like hospitals to be SCHs. CAHs are 
generally smaller with a very limited length of stay, while SCHs 
operate as full-service acute-care hospitals.
    Ninth, a hospital's status as an SCH is not affected by a wage 
index reclassification approved by the MGCRB. A hospital's SCH status 
is affected by an approval for a standardized amount reclassification 
only, as a reclassification for purposes of a hospital's base payment 
rate changes its status for all inpatient hospital prospective payment 
purposes except the wage index.
    Finally, hospitals are encouraged to provide as much documentation 
as possible to assist the fiscal intermediary and CMS in evaluating 
requests for SCH status. The more complete the documentation, the 
quicker a decision can be rendered. If a hospital can provide 
affidavits or other verification of mileage, distances, competing 
hospital locations, etc., then it is encouraged to do so.

B. Rural Referral Centers (Sec. 412.96)

    Under the authority of section 1886(d)(5)(C)(i) of the Act, the 
regulations at Sec. 412.96 set forth the criteria a hospital must meet 
in order to receive special treatment under the prospective payment 
system as a rural referral center. For discharges occurring before 
October 1, 1994, rural referral centers received the benefit of payment 
based on the other urban amount rather than the rural standardized 
amount. Although the other urban and rural standardized amounts were 
the same for discharges beginning with that date, rural referral 
centers would continue to receive special treatment under both the 
disproportionate share hospital (DSH) payment adjustment and the 
criteria for geographic reclassification.
    Section 401 of Public Law 106-113 amended section 1886(d)(8) of the 
Act by adding subparagraph (E), which creates a mechanism, separate and 
apart from the MGCRB, permitting an urban hospital to apply to the 
Secretary to be treated as being located in the rural area of the State 
in which the hospital is located. The statute directs the Secretary to 
treat a qualifying hospital as being located in the rural area for 
purposes of provisions under section 1886(d) of the Act. Congress 
clearly intended hospitals that become rural under section 
1886(d)(8)(E) of the Act to receive some benefit as a result. In 
addition, one of the criteria under section 1886(d)(8)(E) of the Act is 
that the hospital would qualify as an SCH or a rural referral center if 
it were located in a rural area. An SCH would be eligible to be paid on 
the basis of the higher of its hospital-specific rate or the Federal 
rate. On the other hand, the only benefit under section 1886(d) of the 
Act for an urban hospital to become a rural referral center would be 
waiver of the proximity requirements that are otherwise applicable 
under the MGCRB process, as set forth in Sec. 412.230(a)(3)(i).
    In the August 1, 2000 final rule (65 FR 47089), we stated that we 
believed Congress contemplated that hospitals might seek to be 
reclassified as rural under section 1886(d)(8)(E) of the Act in order 
to become rural referral centers so that the hospitals would be exempt 
from the MGCRB proximity requirement and could be reclassified by the 
MGCRB to another urban area. Therefore, in that final rule we sought a 
policy approach that would appropriately address our concern that these 
urban to rural redesignations not be utilized inappropriately, and that 
would benefit hospitals seeking to reclassify under the MGCRB process 
by achieving rural referral center status. (We became aware of several 
specific hospitals that were rural referral centers for FY 1991, but 
subsequently lost their status when the county in which they were 
located became urban, and had expressed their wish to be redesignated 
as a rural referral center in order to be eligible to reclassify.) 
Accordingly, in light of section 1886(d)(8)(E) of the Act and the 
language in the accompanying Conference Report, effective as of October 
1, 2000, hospitals located in what is now an urban area, if they were 
ever a rural referral center, were reinstated to rural referral center 
status.

[[Page 39877]]

    In addition, as discussed in 62 FR 45999 and 63 FR 26317, under 
section 4202 of Public Law 105-33, a hospital that was classified as a 
rural referral center for FY 1991 is to be classified as a rural 
referral center for FY 1998 and later years so long as that hospital 
continued to be located in a rural area and did not voluntarily 
terminate its rural referral center status. Otherwise, a hospital 
seeking rural referral center status must satisfy applicable criteria. 
One of the criteria under which a hospital may qualify as a rural 
referral center is to have 275 or more beds available for use. A rural 
hospital that does not meet the bed size requirement can qualify as a 
rural referral center if the hospital meets two mandatory prerequisites 
(specifying a minimum case-mix index and a minimum number of 
discharges) and at least one of three optional criteria (relating to 
specialty composition of medical staff, source of inpatients, or 
referral volume). With respect to the two mandatory prerequisites, a 
hospital may be classified as a rural referral center if its--
     Case-mix index is at least equal to the lower of the 
median case-mix index for urban hospitals in its census region, 
excluding hospitals with approved teaching programs, or the median 
case-mix index for all urban hospitals nationally; and
     Number of discharges is at least 5,000 per year, or if 
fewer, the median number of discharges for urban hospitals in the 
census region in which the hospital is located. (The number of 
discharges criterion for an osteopathic hospital is at least 3,000 
discharges per year.)
1. Case-Mix Index
    Section 412.96(c)(1) provides that CMS will establish updated 
national and regional case-mix index values in each year's annual 
notice of prospective payment rates for purposes of determining rural 
referral center status. The methodology we use to determine the 
national and regional case-mix index values is set forth in regulations 
at Sec. 412.96(c)(1)(ii). The proposed national case-mix index value 
for FY 2002 in the May 4 proposed rule included all urban hospitals 
nationwide, and the proposed regional values for FY 2002 were the 
median values of urban hospitals within each census region, excluding 
those with approved teaching programs (that is, those hospitals 
receiving indirect medical education payments as provided in 
Sec. 412.105). Those values were based on discharges occurring during 
FY 2000 (October 1, 1999 through September 30, 2000) and included bills 
posted to CMS's records through December 2000. (The proposed rule 
language erroneously cited the period as FY 1999 (October 1, 1998 
through September 30, 1999.)
    We proposed that, in addition to meeting other criteria, hospitals 
with fewer than 275 beds, if they are to qualify for initial rural 
referral center status for cost reporting periods beginning on or after 
October 1, 2001, must have a case-mix index value for FY 2000 that is 
at least--
     1.3286; or
     The median case-mix index value for urban hospitals 
(excluding hospitals with approved teaching programs as identified in 
Sec. 412.105) calculated by CMS for the census region in which the 
hospital is located. (See the table set forth in the May 4, 2001 
proposed rule at 66 FR 22687.)Based on the latest data available (FY 
2000 bills received through March 31, 2001), in addition to meeting 
other criteria, hospitals with fewer than 275 beds, if they are to 
qualify for initial rural referral center status for cost reporting 
periods beginning on or after October 1, 2001, must have a case-mix 
index value for FY 2000 that is at least--
     1.3289; or
     The median case-mix index value for urban hospitals 
(excluding hospitals with approved teaching programs as identified in 
Sec. 412.105) calculated by CMS for the census region in which the 
hospital is located. The final median case-mix values by region are set 
forth in the following table:

------------------------------------------------------------------------
                                                               Case-Mix
                           Region                            Index Value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................       1.2381
2. Middle Atlantic (PA, NJ, NY)............................       1.2319
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).....       1.3055
4. East North Central (IL, IN, MI, OH, WI).................       1.2588
5. East South Central (AL, KY, MS, TN).....................       1.2530
6. West North Central (IA, KS, MN, MO, NE, ND, SD).........       1.1690
7. West South Central (AR, LA, OK, TX).....................       1.2443
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)...............       1.3275
9. Pacific (AK, CA, HI, OR, WA)............................       1.2991
------------------------------------------------------------------------

    Hospitals seeking to qualify as rural referral centers or those 
wishing to know how their case-mix index value compares to the criteria 
should obtain hospital-specific case-mix values from their fiscal 
intermediaries. Data are available on the Provider Statistical and 
Reimbursement (PS&R) System. In keeping with our policy on discharges, 
these case-mix index values are computed based on all Medicare patient 
discharges subject to DRG-based payment.
2. Discharges
    Section 412.96(c)(2)(i) provides that CMS will set forth the 
national and regional numbers of discharges in each year's annual 
notice of prospective payment rates for purposes of determining rural 
referral center status. As specified in section 1886(d)(5)(C)(ii) of 
the Act, the national standard is set at 5,000 discharges. However, in 
the May 4 proposed rule, we proposed to update the regional standards 
based on discharges for urban hospitals' cost reporting periods that 
began during FY 2000 (that is, October 1, 1999 through September 30, 
2000). (The proposed rule language erroneously cited the period as FY 
1999 (October 1, 1998 through September 30, 1999.) That is the latest 
year for which we have complete discharge data available.
    Therefore, we proposed that, in addition to meeting other criteria, 
a hospital, if it is to qualify for initial rural referral center 
status for cost reporting periods beginning on or after October 1, 
2001, must have as the number of discharges for its cost reporting 
period that began during FY 2000 a figure that is at least--
     5,000; or
     The median number of discharges for urban hospitals in the 
census region in which the hospital is located. (See the table set 
forth in the May 4, 2001 proposed rule at 66 FR 22687.)

[[Page 39878]]

    Based on the latest discharge data available for FY 2000, the final 
median number of discharges for urban hospitals by census region areas 
are as follows:

------------------------------------------------------------------------
                                                             Number of
                         Region                             Discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................           7,064
2. Middle Atlantic (PA, NJ, NY).........................           8,488
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA,WV)...           8,562
4. East North Central (IL, IN, MI, OH, WI)..............           7,616
5. East South Central (AL, KY, MS, TN)..................           6,276
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......           5,210
7. West South Central (AR, LA, OK, TX)..................           6,196
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............           8,878
9. Pacific (AK, CA, HI, OR, WA).........................           7,106
------------------------------------------------------------------------

    We reiterate that an osteopathic hospital, if it is to qualify for 
rural referral center status for cost reporting periods beginning on or 
after October 1, 2001, must have at least 3,000 discharges for its cost 
reporting period that began during FY 2000.
    We did not receive any comments on the criteria for rural referral 
centers.

C. Indirect Medical Education (IME) Adjustment (Sec. 412.105)

1. IME Adjustment Factor Formula Multiplier (Section 111 of Public Law 
106-113 and section 302 of Public Law 106-554 and Sec. 412.105(d)(3)).
    Section 1886(d)(5)(B) of the Act provides that prospective payment 
hospitals that have residents in an approved graduate medical education 
(GME) program receive an additional payment to reflect the higher 
indirect operating costs associated with GME. The regulations regarding 
the calculation of this additional payment, known as the indirect 
medical education (IME) adjustment, are located at Sec. 412.105. The 
additional payment is based in part on the applicable IME adjustment 
factor. The IME adjustment factor is calculated using a hospital's 
ratio of residents to beds, which is represented as r, and a 
multiplier, which is represented as c, in the following equation: c  x  
[(1 + r)\.405\-1]. The formula is traditionally described in terms of a 
certain percentage increase in payment for every 10-percent increase in 
the resident-to-bed ratio.
    Section 302 of Public Law 106-554 amended section 1886(d)(5)(B) of 
the Act to modify the transition for the IME formula multiplier, or c, 
that was first established by Public Law 105-33 and revised by Public 
Law 106-113.
    As discussed in the August 1, 2000 final rule and the June 13, 2001 
interim final rule with comment period, section 111(a) of Public Law 
106-113 revised the formula multiplier for discharges occurring during 
FY 2001 (established under Public Law 105-33 at 1.6) to 1.54. However, 
section 302(b) of Public Law 106-554 provides a special payment rule 
which states that, for discharges occurring on or after April 1, 2001 
and before October 1, 2001, IME payments are to be made as if `c' 
equaled 1.66, rather than 1.54. The multiplier of 1.54 for the first 6 
months of FY 2001 represents a 6.25 percent increase in the level of 
the IME adjustment for every 10 percent increase in the resident-to-bed 
ratio, and the multiplier for the second 6 months of FY 2001 represents 
a 6.75 percent increase in the level of the IME adjustment for every 10 
percent increase in the resident-to-bed ratio. This results in an 
aggregate 6.5 percent increase for every 10 percent increase in the 
resident-to-bed ratio for FY 2001. Section 547(a)(2) of Public Law 106-
554 provides further clarification that these payment increases will 
not apply to discharges occurring after FY 2001 and will not be taken 
into account in calculating the payment amounts applicable for 
discharges occurring after FY 2001. In the June 13 interim final rule, 
we revised Sec. 412.105(d)(3)(v) to reflect the additional payment 
provided for discharges occurring during FY 2001 under section 302(b) 
of Public Law 106-554.
    As discussed in the May 4, 2001 proposed rule, section 302(a) of 
Public Law 106-554 provides that, for discharges occurring during FY 
2002, the formula multiplier is 1.6. For discharges occurring during FY 
2003 and thereafter, the formula multiplier is 1.35. As explained 
above, section 302(b) of Public Law 106-554 provides for a special 
payment rule which states that, for discharges occurring on or after 
April 1, 2001 and before October 1, 2001, IME payments are to be made 
as if ``c'' equaled 1.66 rather than 1.54. The multiplier of 1.6 for FY 
2002 represents a 6.5 percent increase for every 10 percent increase in 
the resident-to-bed ratio. The multiplier for FY 2003 and thereafter 
(1.35) represents a 5.5-percent increase for every 10-percent increase 
in the resident-to-bed ratio. In the May 4 proposed rule, we proposed 
to revise Sec. 412.105(d)(3)(vi) to reflect the change in the formula 
multiplier for FY 2002 to 1.6 as made by section 302(a) of Public Law 
106-554 for discharges occurring during FY 2002. We also proposed to 
add Sec. 412.105(d)(3)(vii) to incorporate the formula multiplier of 
1.35 for discharges occurring on or after October 1, 2002.
    We did not receive any comments on the IME formula provisions of 
the June 13 interim final rule with comment period or the proposed 
amendments under the May 4 proposed rule. Therefore, we are adopting 
both changes to Sec. 412.105(d)(3) as final without change.
2. Resident-to-Bed Ratio Cap (Sec. 412.105(a)(1))
    In the May 4, 2001 proposed rule, we indicated that it had come to 
our attention that there is some misunderstanding about 
Sec. 412.105(a)(1) regarding the determination of the resident-to-bed 
ratio that is used in calculating the IME adjustment. Section 
4621(b)(1) of Public Law 105-33 amended section 1886(d)(5)(B) of the 
Act by adding a new clause (vi) to provide that, effective for cost 
reporting periods beginning on or after October 1, 1997, the resident-
to-bed ratio may not exceed the ratio calculated during the prior cost 
reporting period (after accounting for the cap on the hospital's number 
of full-time equivalent (FTE) residents). We implemented this policy in 
the August 29, 1997 final rule with comment period (62 FR 46003) and 
the May 12, 1998 final rule (63 FR 26323) under regulations at 
Sec. 412.105(a)(1). Existing Sec. 412.105(a)(1) specifies that 
``[e]xcept for the special circumstances for affiliated groups and new 
programs described in paragraphs (f)(1)(vi) and (f)(1)(vii) of this 
section, for a hospital's cost reporting periods beginning on or

[[Page 39879]]

after October 1, 1997, this ratio may not exceed the ratio for the 
hospital's most recent prior cost reporting period.'' In the May 4 
proposed rule, we proposed to clarify Sec. 412.105(a)(1) to add a 
provision that this ratio may not exceed the ratio for the hospital's 
most recent prior cost reporting period after accounting for the cap on 
the number of FTE residents.
    In general, the resident-to-bed ratio from the prior cost reporting 
period, which is to be used as the cap on the resident-to-bed ratio for 
the current payment cost reporting period, should only include an FTE 
count subject to the FTE cap on the number of allopathic and 
osteopathic residents, but is not subject to the rolling average. (An 
explanation of rolling average appears in section IV.H.3. of this 
preamble.)
    The following illustrates the steps for determining the resident-
to-bed ratio for the current payment year cost reporting period and the 
cap on the resident-to-bed ratio:
    Current payment year cost reporting period resident-to-bed ratio:
    Step 1. Determine the hospital's number of FTE residents in the 
current payment year cost reporting period.
    Step 2. Compare the number of allopathic and osteopathic FTEs from 
step 1 to the hospital's FTE cap (Sec. 412.105(f)(1)(iv)). If the 
number of allopathic and osteopathic FTEs from step 1 exceeds the FTE 
cap, replace it with the number of FTEs in the FTE cap. Add any dental 
and podiatry FTEs from step 1 to the capped allopathic and osteopathic 
FTE count.
    Step 3. Determine the 3-year rolling average of the FTE residents 
using the FTEs from the current payment year cost reporting period and 
the prior two cost reporting periods (subject to the FTE cap in each 
cost reporting period). (Include podiatry and dental residents, and 
exclude residents in new programs in accordance with 
Sec. 412.105(f)(1)(iv) and revised (f)(1)(v). Residents in new programs 
are added to the quotient of the rolling average.)
    Step 4. Determine the hospital's number of beds (see 
Sec. 412.105(b)) in the current payment year cost reporting period.
    Step 5. Determine the ratio of the number of FTEs from step 3 to 
the number of beds from step 4. The lower of this resident-to-bed ratio 
or the resident-to-bed ratio cap (calculated below) from the 
immediately preceding cost reporting period is used to calculate the 
hospital's IME adjustment factor for the current payment year cost 
reporting period.
    Resident-to-bed ratio cap:
    Step 1. Determine the hospital's number of FTE residents in its 
cost reporting period that immediately precedes the current payment 
year cost reporting period.
    Step 2. Compare the number of allopathic and osteopathic FTEs from 
step 1 to the hospital's FTE cap. If the number of allopathic and 
osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the 
number of FTEs in the FTE cap. Add any dental and podiatry FTEs from 
step 1 to the capped allopathic and osteopathic FTE count. (If there is 
an increase in the number of FTEs in the current payment year cost 
reporting period due to a new program or an affiliation agreement, 
these FTEs are added to FTEs in the preceding cost reporting period 
after applying the FTE cap.)
    Step 3. Determine the hospital's number of beds (Sec. 412.105(b)) 
in its cost reporting period that immediately precedes the current 
payment year cost reporting period.
    Step 4. Determine the ratio of the number of FTEs in step 2 to the 
number of beds in step 3. This ratio is the resident-to-bed ratio cap 
for the current payment year cost reporting period.
    Step 5. Compare the resident-to-bed ratio cap in step 4 to the 
resident-to-bed ratio in the current payment year cost reporting 
period. The lower of the resident-to-bed ratio from the current payment 
year cost reporting period or the resident-to-bed ratio cap from the 
immediately preceding cost reporting period is used to calculate the 
hospital's IME adjustment factor for the current payment year cost 
reporting period.
    We note that the resident-to-bed ratio cap is a cap on the 
resident-to-bed ratio calculated for all residents, including 
allopathic, osteopathic, dental, and podiatry residents (63 FR 26324, 
May 12, 1998). However, as described in existing Sec. 412.105(a)(1), 
the resident-to-bed ratio cap may be adjusted to reflect an increase in 
the current cost reporting period's resident-to-bed ratio due to 
residents in a new GME program or an affiliation agreement. While an 
exception does not apply if the resident-to-bed ratio increases because 
of an increase in the number of podiatry or dentistry residents or 
because of a change in the number of beds, the ratio could increase 
after a one-year delay. An increase in the current cost reporting 
period's ratio (while subject to the FTE cap on the overall number of 
allopathic and osteopathic residents) thereby establishes a higher cap 
for the following cost reporting period.
    The following is an example of the application of the cap on the 
resident-to-bed ratio:

    Example--Part 1:   

     Assume Hospital A has 50 FTEs in its cost reporting 
period ending September 30, 1996, thereby establishing an IME FTE 
resident cap of 50 FTEs.
     In its cost reporting period of October 1, 1996 to 
September 30, 1997 (the prior year), it has 50 FTEs and 200 beds, so 
that its resident-to-bed ratio for this period is 50/200 = .25.
     In the (current year) cost reporting period of October 
1, 1997 to September 30, 1998 (the first cost reporting period in 
which the FTE resident cap, the resident-to-bed ratio cap, and the 
rolling average apply), Hospital A has 50 FTEs and 200 beds.
     Hospital A's FTEs do not exceed its FTE cap, so its 
current number of FTEs (50) is used to calculate the 2-year rolling 
average: (50 + 50)/2 = 50.
     The result of the rolling average is used as the 
numerator of the resident-to-bed ratio. Thus, the resident-to-bed 
ratio is 50/200 = .25.
     .25 is compared to the resident-to-bed ratio from the 
prior period of October 1, 1996 to September 30, 1997. Because the 
FTE resident cap and the rolling average were not yet effective in 
the period of October 1, 1996 to September 30, 1997, that period s 
resident-to-bed ratio does not have to be recalculated to account 
for the FTE resident cap. Accordingly, the resident-to-bed ratio cap 
for October 1, 1997 to September 30, 1998 is .25.
     Because the resident-to-bed ratio does not exceed the 
prior year ratio, Hospital A would use the resident-to-bed ratio of 
.25 to determine the IME adjustment in its cost reporting period of 
October 1, 1997 to September 30, 1998.

    Example--Part 2:   

     In the (current year) cost reporting period of October 
1, 1998 to September 30, 1999, Hospital A adds 1 podiatric and 1 
dental resident, so that it has a total of 52 FTEs and 200 beds. 
Since the FTE resident cap only includes allopathic and osteopathic 
residents, Hospital A has not exceeded its FTE resident cap with the 
addition of a podiatric and a dental resident.
     Accordingly, the (now) 3-year rolling average would be 
(52 + 50 + 50)/3 = 50.67.
     50.67 is used in the numerator of the current payment 
year's resident-to-bed ratio, so that the resident-to-bed ratio is 
50.67/200 = .253.
     .253 is compared to the resident-to-bed ratio from the 
prior year's cost reporting period of October 1, 1997 to September 
30, 1998 that is recalculated to account for the FTE resident cap. 
Because Hospital A did not exceed its FTE resident cap of 50 FTEs in 
this period of October 1, 1997 to September 30, 1998, the 
recalculated resident-to-bed ratio would be 50/200 = .25.
     Compare the current year resident-to-bed ratio (.253) 
to the resident-to-bed ratio cap (.25); .253 does exceed .25.
     Therefore, the resident-to-bed ratio in the period of 
October 1, 1998 to September 30, 1999 is capped at .25, which is to 
be used in calculating Hospital A s IME adjustment for October 1, 
1998 to September 30, 1999.

    Example--Part 3:   

     In the cost reporting period of October 1, 1999 to 
September 30, 2000, Hospital A adds

[[Page 39880]]

2 internal medicine residents so that it has a total of 54 FTEs and 
200 beds. While podiatric and dental residents are not included in 
the FTE resident cap, internal medicine residents are included. 
Hospital A has exceeded its IME FTE resident cap of 50 by 2 FTEs. 
Thus, 2 FTEs are excluded from the FTE count.
     Accordingly, the rolling average would be (52 + 52 + 
50)/3 = 51.33.
     51.33 is used in the numerator of the resident-to-bed 
ratio, so that the resident-to-bed ratio is 51.33/200 = .257.
     .257 is compared to the resident-to-bed ratio from 
October 1, 1998 to September 30, 1999 that is recalculated to only 
account for the FTE resident cap. The recalculated resident-to-bed 
ratio would be 50 allopathic or osteopathic FTEs plus 1 podiatric 
and 1 dental resident, which is 52/200 = .26.
     .26 is the resident-to-bed ratio cap for October 1, 
1999 to September 30, 2000. .257 does not exceed .26.
     Therefore, the resident-to-bed ratio in the period of 
October 1, 1998 to September 30, 1999 is .257, which is to be used 
in calculating this period s IME adjustment.
    If a hospital starts a new GME program, the adjustment to the 
resident-to-bed ratio cap applies for the period of years equal to the 
minimum accredited length for each new program started. (For example, 
for a new internal medicine program, the period of years equals 3; for 
a new surgery program, the period of years equals 5.) Within these 
program years, the number of new FTE residents in the current cost 
reporting period is added to the FTE resident count used in the 
numerator of the resident-to-bed ratio from the previous cost reporting 
period. The lower of the resident-to-bed ratio from the current cost 
reporting period or the adjusted resident-to-bed ratio from the 
preceding cost reporting period is used to calculate the hospital's IME 
adjustment for the current cost reporting period. If a hospital 
subsequently continues to expand its program, the numerator of the 
resident-to-bed ratio from the preceding cost reporting period would 
not be adjusted to reflect these additional residents. However, an 
increase in the ratio of the current cost reporting period would 
establish a higher cap for the following cost reporting period.
    We also proposed to add a provision that the exception for new 
programs described in Sec. 412.105(f)(1)(vii) applies for the period of 
years equal to the minimum accredited length for each new program.
    Similarly, if a hospital increases the number of FTE residents in 
the current cost reporting period because of an affiliation agreement, 
the number of additional FTEs is added to the FTE resident count used 
in the numerator of the resident-to-bed ratio from the previous cost 
reporting period. The lower of the resident-to-bed ratio from the 
current cost reporting period or the adjusted resident-to-bed ratio 
from the preceding cost reporting period is used to calculate the 
hospital's IME adjustment for the current cost reporting period.
    Comment: Several commenters addressed our clarifications to the 
regulations at Sec. 412.105(a)(1) regarding the cap on the resident-to-
bed ratio. One commenter stated that the explanation in the proposed 
rule regarding the resident-to-bed ratio was thorough. Another 
commenter expressed appreciation for the inclusion of examples in the 
proposed rule's preamble. One commenter noted that, in the proposed 
rule under step 2 of the example of the calculation of the resident-to-
bed ratio cap, we indicate that the lesser of the prior year FTEs or 
the FTE cap is used in the numerator of the resident-to-bed ratio. The 
commenter noted that we do not specify that, while the FTE cap only 
applies to allopathic and osteopathic FTEs, dentistry and podiatry FTEs 
should be included in the numerator of the resident-to-bed ratio. The 
commenter asked that we specify that the prior year podiatry and 
dentistry FTEs must be added to the FTE count used in the resident-to-
bed ratio after the FTE cap has been applied.
    Response: We agree with the commenter concerning the inclusion of 
dental and podiatry FTEs in step 2, and we have clarified the language 
in step 2 of the examples of both the current year resident-to-bed 
ratio and the resident-to-bed ratio cap calculation in the preamble of 
this final rule. Specifically, we state, ``Compare the number of 
allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap. 
If the number of allopathic and osteopathic FTEs from step 1 exceeds 
the FTE cap, replace it with the FTE cap. Add any dental or podiatry 
FTEs from step 1 to the capped allopathic and osteopathic FTE count.'' 
Furthermore, we are revising the proposed changes to the regulations 
text at Sec. 412.105(a)(1) to state that ``. . . this ratio may not 
exceed the ratio for the hospital's most recent prior cost reporting 
period after accounting for the cap on the number of allopathic and 
osteopathic residents as described in paragraph (f)(1)(iv) of this 
section, and adding to the capped numerator any dental and podiatric 
full-time equivalent residents. . . .''
    Comment: One commenter noted that, in clarifying the regulations at 
Sec. 412.105(a)(1) regarding the resident-to-bed ratio cap, we added 
that the exception to the resident-to-bed ratio cap ``. . . for new 
programs . . . applies for the period of years equal to the minimum 
accredited length for that type of program'' (emphasis added). The 
commenter asked how we would apply the exception to the resident-to-bed 
ratio cap in a situation where a hospital has started several new 
programs with varying minimum accredited lengths.
    Response: The exception at proposed Sec. 412.105(a)(1) for new 
programs allows a hospital to add a full complement of residents and 
complete the initial cycle of a program before residents in the new 
programs are included in the application of the resident-to-bed ratio 
cap. In a situation where a hospital has started several new programs 
under Sec. 412.105(f)(1)(vii), we would apply the exception to the 
resident-to-bed ratio cap to each new program individually based on 
each program's minimum accredited length. For example, if a hospital 
simultaneously starts a new internal medicine program (which has a 
minimum accredited length of 3 years) and an anesthesiology program 
(which has a minimum accredited length of 4 years), the FTE residents 
in the new internal medicine program will be subject to the resident-
to-bed ratio cap in the fourth program year of the internal medicine 
program, while the anesthesiology FTE residents would still be excluded 
from the resident-to-bed ratio cap in the fourth program year of the 
anesthesiology programs. However, in subsequent program years, the 
anesthesiology FTE residents would be subject to the resident-to-bed 
ratio cap, as well.
    The rules regarding the exception from the rolling average 
calculation for IME are the same for direct GME. The proposed revised 
regulations at Sec. 412.105(f)(1)(v) and Sec. 413.86(g)(5) in the May 
4, 2001 proposed rule state that FTE residents in a new program are 
excluded from the rolling average calculation for the period of years 
equal to the minimum accredited length for the type of program. In this 
final rule, we are revising the regulations regarding the exceptions to 
the resident-to-bed ratio cap and the rolling average calculation for 
both IME and direct GME to clarify that these exceptions apply to each 
new program individually for which the FTE cap may be adjusted based on 
each program's minimum accredited length (Sec. 412.105(a)(1), 
412.105(f)(1)(v), and 413.86(g)(5)(v)).
    Comment: One commenter asserted that, in the proposed rule, it is 
inconsistent to account for both the FTE cap and the rolling average 
count of residents in the current year resident-to-bed ratio, but 
account for only the FTE cap in the resident-to-bed ratio cap

[[Page 39881]]

(which is the prior year's ratio). The commenter stated that their 
willingness to support the proposed rule depended on whether the 
residency program is increasing or decreasing its FTEs every year.
    Response: Section 1886(d)(5)(B)(v)(I) of the Act, as amended by 
Public Law 105-33, states that the resident-to-bed ratio ``may not 
exceed the ratio of the number of interns and residents, subject to the 
limit under clause (v), with respect to the hospital for its most 
recent cost reporting period to the hospital's available beds . . . 
during that cost reporting period . . .'' (emphasis added). Clause (v) 
is the FTE cap requirement; the statute does not specify clause 
(vi)(II), which is the rolling average requirement, in relation to the 
resident-to-bed ratio cap. Accordingly, the implementing regulations 
require that the resident-to-bed ratio cap should only account for the 
cap on the number of FTEs.
    In addition, we note that the commenter is mistaken in indicating 
that the rules regarding the determination of the resident-to-bed ratio 
and the resident-to-bed ratio cap are proposed rules. These rules have 
been in place based on the statute since the effective date of Public 
Law 105-33. We simply took the opportunity in the proposed rule 
published on May 4, 2001 to further clarify our existing policy because 
we realized that there was some confusion surrounding these rules.
    Comment: One commenter noted that, since under the provisions of 
Sec. 413.86(g)(6)(i), the FTE cap for new programs is established based 
on the number of residents in the third year of the first program's 
existence, it follows that the FTE cap on the residents in the new 
programs is effective in the fourth program year. The commenter asked 
if the application of the cap is delayed until the expiration of the 
minimum accredited length of the new programs.
    Response: The application of the FTE adjusted caps for new programs 
under Sec. 413.86(g)(6)(i) and (g)(6)(ii) are not delayed until the 
expiration of the minimum accredited length of the new programs. Only 
the application of the resident-to-bed ratio cap for IME and the 
rolling average for both IME and direct GME are dependent upon the 
minimum accredited length of each new program. The regulations at 
Sec. 413.86(g)(6)(i) state that the cap for new programs will be 
adjusted based on ``the product of the highest number of residents in 
any program year during the third year of the first program's existence 
for all new residency training programs and the number of years in 
which residents are expected to complete the program based on the 
minimum accredited length for the type of program'' (emphasis added). 
In general, when a hospital qualifies for a cap adjustment under 
Sec. 413.86(g)(6)(i), the hospital has three years from the time that a 
resident first begins training in the first new program to establish 
its FTE cap. The first day of the fourth program year, the FTE cap on 
that first program, and any other programs that may have been started 
within the initial three years of that first program, is permanently 
established and takes effect.
    For example, if a hospital that qualifies for a cap adjustment 
under Sec. 413.86(g)(6)(i) starts a newly accredited dermatology 
program on July 1, 2001, and then starts a newly accredited 
anesthesiology program on July 1, 2002, the cap for both programs, and 
for the hospital as a whole, will be adjusted as of July 1, 2004, the 
first day of the fourth program year of dermatology, which is the first 
program that the hospital started. The hospital's cap will be based on 
the sum of: (a) The product of the highest number of residents in 
either PGY1, PGY2, or PGY3 in the third year of the dermatology program 
and 4 years (the minimum accredited length of dermatology); and (b) the 
product of the highest number of residents in either PGY1 or PGY2 for 
the anesthesiology program and 4 years (the minimum accredited length 
for anesthesiology). Any programs begun after the first program's start 
date but before the fourth program year of the first program will not 
have a full 3 years before the hospital's cap is permanently adjusted.
    The rules under Sec. 413.86(g)(6)(ii) differ for hospitals that 
qualify for an FTE cap adjustment for new programs started on or after 
January 1, 1995 and on or before August 5, 1997. Section 
413.86(g)(6)(ii) states that the FTE cap adjustment is ``based on the 
product of the highest number of residents in any program year during 
the third year of the newly established program and the number of years 
in which residents are expected to complete the program based on the 
minimum accredited length for the type of program'' (emphasis added). 
In contrast to hospitals that qualify for a cap adjustment under 
Sec. 413.86(g)(6)(i), where the cap for the hospital takes effect for 
all programs in the fourth program year of the first program that was 
started by the hospital, hospitals that qualify for an FTE cap 
adjustment under Sec. 413.86(g)(6)(ii) have a full 3 years to grow each 
new program, as long as those programs all started training residents 
or received accreditation between January 1, 1995 and on or before 
August 5, 1997. The adjustment to the cap for each of those new 
programs would be applied individually, beginning with the first day of 
the fourth program year of each new program. (We note that rural 
hospitals that qualify for a cap adjustment under 
Sec. 413.86(g)(6)(iii) may receive an FTE cap adjustment in the same 
manner as hospitals that qualify for the cap adjustment under 
Sec. 413.86(g)(6)(ii), except that rural hospitals may receive this 
adjustment for programs started after August 5, 1997).
    For example, assume a hospital that qualifies for a cap adjustment 
under Sec. 413.86(g)(6)(ii) started a newly accredited internal 
medicine program on July 1, 1996, and a newly accredited dermatology 
program on July 1, 1997. The adjustment to the hospital's FTE cap 
because of the internal medicine program was effective July 1, 1999 
(the first day of the fourth program year of internal medicine), and 
the cap adjustment resulting from the dermatology program was effective 
July 1, 2000 (the first day of the fourth program year for 
dermatology). The hospital's ultimate FTE cap is the sum of the FTE cap 
based on FTEs in the hospital's most recent cost reporting period 
ending on or before December 31, 1996, and the cap adjustments for the 
internal medicine and dermatology programs. (We note that since the 
internal medicine program began in 1996, depending on the hospital's 
cost reporting period, a portion of those FTEs may have already been 
included in the hospital's FTE cap. That portion that was included in 
the FTE cap must be subtracted from the cap adjustment that was 
calculated for the internal medicine program to avoid any double 
counting of the FTEs). The hospital's adjusted cap will be based on the 
sum of: (a) the product of the highest number of internal medicine 
residents in either PGY1, PGY2, or PGY3 in the third year of the 
internal medicine program and three (the minimum accredited length of 
internal medicine); and (b) the product of the highest number of 
dermatology residents in either PGY1, PGY2, or PGY3 for the dermatology 
program and four (the minimum accredited length for dermatology).
    In summary, we reiterate that the application of the FTE cap 
adjustments for new programs is not delayed until the program year in 
which the minimum accredited length of each program expires. This would 
even apply to a new program with a minimum accredited length that 
exceeds 3 years. The FTE cap adjustment takes effect on the first day 
of the fourth program year of the first new program that was started

[[Page 39882]]

by hospitals qualifying for a cap adjustment under 
Sec. 413.86(g)(6)(i). For hospitals qualifying for a cap adjustment 
under Sec. 413.86(g)(6)(ii) and (g)(6)(iii), the cap adjustments take 
effect on the first day of the fourth program year of each new program. 
However, the application of the resident-to-bed ratio cap for IME and 
the rolling average for both IME and direct GME are dependent upon the 
minimum accredited length of each new program.
    Comment: With regard to the counting of residents for IME payment 
purposes in nonhospital sites, one commenter stated that although time 
spent in nonhospital sites may be included in the IME FTE count 
effective for discharges occurring on or after October 1, 1997, the 
application of the 1996 FTE cap effectively disallows the current 
year's FTEs training in the nonhospital site, because the 1996 FTE cap 
was based on residents training only in the hospital. The commenter 
added that only those hospitals that are in a position to elect a 
Medicare affiliation agreement are able to ``circumvent'' the 1996 FTE 
limit; those that cannot are ``penalized.'' The commenter further 
stated that the regulatory intent of allowing nonhospital training time 
to be counted is not fully met by having only certain hospitals able to 
affiliate. The commenter recommended that we should allow hospitals to 
recalculate the 1996 IME FTE cap to include those FTEs training in 
nonhospital sites, so that hospitals will effectively be able to count 
residents currently training in nonhospital sites for IME purposes.
    Response: The commenter is addressing a provision in Public Law 
105-33 that was implemented in regulations at 
Sec. 412.105(f)(1)(ii)(C). We did not propose any substantive changes 
to this policy; we simply were correcting an oversight in the 
regulations text for IME. (Comments on regulations implementing this 
provision were addressed in the May 12, 1998 final rule (63 FR 26323) 
and the July 31, 1998 final rule (63 FR 40954).)
3. Conforming Changes (Sec. 412.105(f)(1)(ii)(C) and (f)(1)(v))
    In the August 29, 1997 final rule with comment period (62 FR 
46003), the May 12, 1998 final rule (63 FR 26323), and the July 31, 
1998 final rule (63 FR 40986), to implement the provisions of Public 
Law 105-33, we set forth certain policies that affected payment for 
both direct and indirect GME. Some of these policies related to the FTE 
cap on allopathic and osteopathic residents, the rolling average, and 
payment for residents training in nonhospital settings. In the May 4 
proposed rule, we indicated that when we amended the regulations under 
Sec. 413.86 for direct GME, we inadvertently did not make certain 
conforming changes in Sec. 412.105 for IME. We proposed to make the 
following conforming changes:
     To revise Sec. 412.105(f)(1)(ii)(C) to specify that, 
effective for discharges occurring on or after October 1, 1997, the 
time residents spend training in a nonhospital setting in patient care 
activities under an approved medical residency training program may be 
counted towards the determination of full-time equivalency if the 
criteria set forth at Sec. 413.86(f)(3) or Sec. 413.86(f)(4), as 
applicable, are met.
     To revise Sec. 412.105(f)(1)(v) to specify that residents 
in new residency programs are not included in the rolling average for a 
period of years equal to the minimum accredited length for the type of 
program.
    In addition, we proposed to revise Sec. 412.105(f)(1)(ix) to 
specify, for IME purposes, a temporary adjustment to a hospital's FTE 
cap to reflect residents added because of another hospital's closure of 
its medical residency program (to conform to the May 4, 2001 proposed 
change for GME discussed in section IV.H.5. of this preamble).
    We did not receive any comments on these conforming changes and are 
adopting them as final.

D. Payments to Disproportionate Share Hospitals (DSH) (Sections 211 and 
303 of Public Law 106-554 and Sec. 412.106)

    Effective for discharges beginning on or after May 1, 1986, 
hospitals that serve a disproportionate number of low-income patients 
(the DSH patient percentage as defined in section 1886(d)(5)(F) of the 
Act) receive additional payments through the DSH adjustment. Hospitals 
that meet the DSH patient percentage criteria are entitled to the DSH 
payment adjustment.
1. Qualifying Thresholds for DSHs
    In the June 13, 2001 interim final rule with comment period, we 
discussed the provisions of section 1886(d)(5)(F)(v) of the Act, as it 
existed prior to enactment of Public Law 106-554 and under 
Sec. 412.106(c) of the existing regulations, which provided that a 
hospital qualified for DSH if the hospital had a DSH patient percentage 
equal to:
     At least 15 percent for an urban hospital with 100 or more 
beds or a rural hospital with 500 or more beds;
     At least 40 percent for an urban hospital with fewer than 
100 beds;
     At least 45 percent for a rural hospital with 100 beds or 
fewer, if it is not also classified as an SCH;
     At least 30 percent for a rural hospital with more than 
100 beds and fewer than 500 beds or which is classified as an SCH; or
     The hospital has 100 or more beds, is located in an urban 
area, and receives more than 30 percent of its net inpatient revenues 
from State and local government sources for the care of indigent 
patients not eligible for Medicare or Medicaid.
    Section 211(a) of Public Law 106-554 amended section 
1886(d)(5)(F)(v) to provide that, beginning with discharges occurring 
on or after April 1, 2001, the qualifying threshold is reduced to 15 
percent for all hospitals. Therefore, in the June 13 interim final 
rule, we revised Sec. 412.106(c) to reflect the change in DSH 
qualifying threshold percentages.
    Comment: Several commenters responded on the subject of the 
calculation of the DSH payment adjustment. These commenters were 
concerned about how to apply the threshold changes as of April 1, 2000. 
They were also concerned about counting days in the calculation when a 
stay crosses over two cost reporting periods. Finally, these commenters 
were concerned about counting section 1115 expansion waiver days in the 
DSH payment adjustment calculation.
    Response: Section 211(a) of Public Law 106-554 amended section 
1886(d)(5)(F) of the Act to change the qualifying thresholds for the 
DSH payment adjustment to 15 percent for all hospital types, effective 
with discharges occurring on or after April 1, 2001. This means that 
the legislation is effective with discharges occurring on or after 
April 1, 2001, but not before. Therefore, fiscal intermediaries are 
required to determine whether a hospital meets the thresholds in place 
either before or after April 1, 2001, by applying the DSH patient 
percentage in the formula to each separate period. Days are counted 
based on the date of discharge. In other words, a hospital stay would 
be counted in the cost reporting year during which the patient was 
discharged.
    Finally, counting section 1115 expansion waiver days in the DSH 
payment adjustment calculation was discussed in the August 1, 2000 
Federal Register (65 FR 47086). This policy became effective for 
discharges occurring on or after January 20, 2000. Therefore, it is 
possible that a hospital will qualify for DSH payments as of January 
20, 2000, whereas it did not qualify before January 20, 2000, and it 
should be paid accordingly. In other words, a hospital in that 
situation would receive Medicare DSH payments beginning January 20, 
2000.

[[Page 39883]]

2. Calculation of the DSH Payment Adjustment
    Section 211(b) of Public Law 106-554 further amended section 
1886(d)(5)(F) to revise the calculation of the DSH payment adjustment 
for hospitals affected by the revised thresholds as specified in 
section 211(a) of the Act. In the June 13 interim final rule with 
comment period, we discussed these adjustments, which are effective for 
discharges occurring on or after April 1, 2001, as follows:
     Urban hospitals with fewer than 100 beds and whose DSH 
patient percentage is equal to or greater than 15 percent and less than 
19.3 percent receive the DSH payment adjustment determined using the 
following formula:
    (DSH patient percentage - 15) (.65) + 2.5.
     Urban hospitals with fewer than 100 beds and whose DSH 
patient percentage is equal to or greater than 19.3 percent receive a 
flat add-on of 5.25 percent.
     Rural hospitals that are both rural referral centers and 
SCHs receive the DSH payment adjustment determined using the higher of 
the SCH adjustment or the rural referral center adjustment.
     Rural hospitals that are SCHs and are not rural referral 
centers and whose DSH patient percentage is equal to or greater than 15 
percent and less than 19.3 percent receive the DSH payment adjustment 
determined using the following formula:
    (DSH patient percentage - 15) (.65) + 2.5.
     Rural hospitals that are SCHs and are not rural referral 
centers and whose DSH patient percentage is equal to or greater than 
19.3 percent and less than 30 percent receive a flat add-on of 5.25 
percent.
     Rural hospitals that are SCHs and are not rural referral 
centers and whose DSH patient percentage is equal to or greater than 30 
percent receive 10 percent.
     Rural referral centers whose DSH patient percentage is 
greater than or equal to 15 percent and less than 19.3 percent receive 
the DSH payment adjustment determined using the following formula:
    (DSH patient percentage - 15) (.65) + 2.5.
     Rural referral centers whose DSH patient percentage is 
equal to or greater than 19.3 percent but less than 30 percent receive 
a flat add-on of 5.25 percent.
     Rural referral centers whose DSH patient percentage is 
equal to or greater than 30 percent receive the DSH payment adjustment 
determined using the following formula:
    (DSH patient percentage--30) (.6) + 5.25.
     Rural hospitals with fewer than 500 beds and whose DSH 
patient percentage is equal to or greater than 15 percent and less than 
19.3 percent receive the DSH payment adjustment using the following 
formula:
    (DSH patient percentage--15) (.65) + 2.5.
     Rural hospitals with fewer than 500 beds and whose DSH 
patient percentage is equal to or greater than 19.3 percent receive a 
flat add-on of 5.25 percent.
    If we calcqulate DSH patient percentages to the hundredth place 
(our current practice), these payment formulas result in an anomaly for 
some DSH patient percentages just below 19.3 percent (but greater than 
19.2 percent). That is, as the percentage values approach 19.3, the DSH 
payment adjustment resulting from the formula exceeds 5.25 percent. 
This would result in a higher DSH payment adjustment for DSH patient 
percentages just below 19.3 than for percentages of 19.3 and above. We 
stated in the June 13 interim final rule that, because we believe it 
would be contrary to the Congress' intent for hospitals with a DSH 
patient percentage of less than 19.3 percent to receive a greater 
payment than those hospitals of the same class that have a DSH patient 
percentage of 19.3 or greater, we were implementing this provision so 
that, for DSH patient percentages below 19.3 for affected hospitals, 
the DSH payment adjustment will not exceed 5.25 percent.
    In the June 13 interim final rule with comment period, we revised 
Sec. 412.106(d) to reflect the changes in the disproportionate share 
adjustment.
3. Percentage Reduction to the DSH Payment Adjustment
    Section 1886(d)(5)(F)(ix) of the Act, as amended by section 112 of 
Public Law 106-113, specifies a percentage reduction in the payments a 
hospital would otherwise receive under the DSH payment adjustment 
formula. Prior to enactment of section 303 of Public Law 106-554, the 
reduction percentages were as follows: 3 percent for FY 2001, 4 percent 
for FY 2002, and 0 percent for FY 2003 and each subsequent fiscal year.
    Section 303 of Public Law 106-554 revised the amount of the percent 
reductions to 2 percent for discharges occurring in FY 2001, and to 3 
percent for discharges occurring in FY 2002. The reduction continues to 
be 0 percent for FY 2003 and each subsequent fiscal year. Section 303 
of Public Law 106-554 contains a special rule for FY 2001: For 
discharges occurring on or after October 1, 2000 and before April 1, 
2001, the reduction is to be 3 percent, and for discharges occurring on 
or after April 1, 2001 and before October 1, 2001, the reduction is to 
be 1 percent. Changes made by section 303 with respect to FY 2001 
discharges were implemented in the June 13, 2001 interim final rule 
with comment period.
    We are adopting as final the revisions to Sec. 412.106(e) to 
reflect the change in the percentages made by section 303 of Public Law 
106-554 that were included in the May 4, 2001 proposed rule and in the 
June 13, 2001 interim final rule with comment period. We also are 
making a technical change in the heading of paragraph (e).

E. Medicare-Dependent, Small Rural Hospitals (Section 404 of Public Law 
106-113 and section 212 of Public Law 106-554 and 42 CFR 412.90(j) and 
412.108)

    Section 6003(f) of the Omnibus Budget Reconciliation Act of 1989 
(Public Law 101-239) added section 1886(d)(5)(G) to the Act and created 
the category of Medicare-dependent, small rural hospital (MDH) that are 
eligible for a special payment adjustment under the hospital inpatient 
prospective payment system. Section 1886(d)(5)(G) of the Act define an 
MDH as any hospital that meets all of the following criteria:
     The hospital is located in a rural area.
     The hospital has 100 or fewer beds.
     The hospital is not classified as an SCH (as defined at 
Sec. 412.92).
     In the hospital's cost reporting period that began during 
FY 1987, not less than 60 percent of its inpatient days or discharges 
were attributable to inpatients entitled to Medicare Part A benefits. 
If the cost reporting period is for less than 12 months, the hospital's 
most recent 12-month or longer cost reporting period before the short 
period is used.
    (For a more detailed discussion, see the April 20, 1990 Federal 
Register (55 FR 15154)).
    As provided by the law, MDHs were eligible for a special payment 
adjustment under the prospective payment system, effective for cost 
reporting periods beginning on or after April 1, 1990 and ending on or 
before March 31, 1993. Hospitals classified as MDHs were paid using the 
same methodology applicable to SCHs, that is, based on whichever of the 
following rates yielded the greatest aggregate payment for the cost 
reporting period:
     The national Federal rate applicable to the hospital.
     The updated hospital-specific rate using FY 1982 cost per 
discharge.

[[Page 39884]]

     The updated hospital-specific rate using FY 1987 cost per 
discharge.
    Section 13501(e)(1) of the Omnibus Budget Reconciliation Act of 
1993 (Public Law 103-66) extended the MDH provision through FY 1994 and 
provided that, after the hospital's first three 12-month cost reporting 
periods beginning on or after April 1, 1990, the additional payment to 
an MDH whose applicable hospital-specific rate exceeded the Federal 
rate was limited to 50 percent of the amount by which the hospital-
specific rate exceeded the Federal rate.
    Section 4204(a)(3) of Public Law 105-33 reinstated the MDH special 
payment for discharges occurring on or after October 1, 1997 and before 
October 1, 2001, but did not revise the qualifying criteria for these 
hospitals or the payment methodology.
    Section 404(a) of Public Law 106-113 extended the MDH provision to 
discharges occurring on or after October 1, 2002 and before October 1, 
2006. In the August 1, 2000 interim final rule with comment period, we 
revised Secs. 412.90(j) and 412.108 to reflect the extension of the MDH 
program through FY 2006.
    As specified in the June 13, 2001 interim final rule with comment 
period, section 212 of Public Law 106-554 provided that, effective with 
cost reporting periods beginning on or after April 1, 2001, hospitals 
have the option to base MDH eligibility on two of the three most 
recently audited cost reporting periods for which the Secretary has a 
settled cost report, rather than on the cost reporting period that 
began during FY 1987. According to section 212, the criteria for at 
least 60 percent Medicare utilization will be met if in at least ``2 of 
the 3 most recently audited cost reporting periods for which the 
Secretary has a settled cost report'', at least 60 percent of the 
hospital's inpatient days or discharges were attributable to 
individuals receiving Medicare Part A benefits.
    Hospitals that qualify under this provision are subject to the 
other provisions already in place for MDHs, that is, the payment 
methodology as defined in Sec. 412.108(c) and the volume decrease 
provision as defined in Sec. 412.108(d).
    A hospital must notify its fiscal intermediary to be considered for 
MDH status under this new provision. Any hospital that believes it 
meets the criteria to qualify as an MDH, based on at least two of its 
three most recently settled cost reports, must submit a written request 
to its intermediary. The hospital's request must be submitted within 
180 days from the date of the notice of amount of program reimbursement 
for the cost reporting period in question. The intermediary will make 
its determination and notify the hospital within 180 days from the date 
it receives the hospital's request and all of the required 
documentation.
    In the June 13 interim final rule with comment period, we revised 
Sec. 412.108(a)(1)(iii) to reflect the additional option provided by 
section 212 of Public Law 106-554.
    We received one comment on the proposed regulation change.
    Comment: One commenter representing a state hospital association 
expressed concern regarding the MDH qualifying process outlined in the 
interim final rule. The commenter questioned the timing of the process, 
especially that the hospital would be required to apply within 180 days 
from the date of the notice of program reimbursement and that the 
fiscal intermediary would have up to 180 days in which to make its 
decision. The commenter believed that this would not allow hospitals to 
qualify by the first cost reporting period beginning on or after the 
April 1, 2001, effective date of the new provision. The commenter also 
believed that this process would result in a lengthy period of time, 
perhaps 2-4 years while the cost report settlement and this process 
plays out. The commenter also believed the determination of whether or 
not a hospital meets the requirements to become an MDH under this new 
provision should be handled in manner consistent with that already in 
place. That is, fiscal intermediaries should automatically determine, 
using the cost report information they have, whether or not any 
additional hospitals would now qualify as an MDH under this new 
criteria, rather than putting the burden on the hospitals to apply for 
MDH status. The commenter also stated that the fiscal intermediaries 
require instruction regarding the calculation of the payment rates in 
order to determine which would most benefit the MDHs. The commenter 
also believed that the impact analysis understates the number of newly 
eligible hospitals under the new MDH provision.
    Response: We disagree with the commenter that the process for 
approval of new MDHs could take as long as 2 to 4 years. We do agree 
with this commenter that hospitals' requests for consideration under 
this provision need not be limited to requests submitted within 180 
days of the issuance of a notice of amount of program reimbursement, 
and we are deleting this requirement from Sec. 412.108(b). This will 
eliminate any unintended delay in the time when hospitals could request 
MDH status. Therefore, hospitals are free to request MDH status at any 
time. We also are revising the time provided for fiscal intermediaries 
to make their determination, from 180 days to 90 days. We believe this 
will provide sufficient time for review while being responsive to the 
commenter's concern that the process not be too lengthy. Similar to the 
approval period for SCHs as described above, MDH status and the 
associated payment adjustment are effective 30 days after written 
notification to the MDH.
    We believe it is most appropriate, and consistent with procedures 
for SCH and rural referral center designation, to require hospitals to 
request consideration as a MDH, rather than placing this requirement 
with the fiscal intermediaries. We will further clarify the MDH policy 
and process, including the change noted above, through future Program 
Memoranda.
    With respect to the commenter's concern that our impact analysis 
underestimates the number of newly eligible hospitals under the new 
provision, we noted in the June 13, 2001 interim final rule with 
comment period that our most recent data available were 1998, and we 
were, therefore, unable to estimate the impacts using more recent data. 
Therefore, the actual impact of this provision may be different as the 
fiscal intermediaries evaluated hospitals' requests using more recent 
data.

F. Reclassification of Certain Urban Hospitals as Rural Hospitals 
(Sections 401(a) and (b) of Public Law 106-113 and 42 CFR 412.63(b), 
412.90(e), 412.102, and 412.103)

1. Permitting Reclassification of Certain Urban Hospitals as Rural 
Hospitals
    Under Medicare law, the location of a hospital can affect its 
payment methodology as well as whether the facility qualifies for 
special treatment both for operating and for capital payments. Whether 
a facility is situated in an urban or a rural area will, for example, 
affect payments based on the wage index values and Federal standardized 
amounts specific to the area. Similarly, the percentage increase in 
payments made to hospitals that treat a disproportionate share of low-
income patients is based, in part, on its urban/rural status, as are 
determinations regarding a hospital's qualification as an SCH, rural 
referral center, critical access hospital (CAH), or other special 
category of facility. Section 1886(d)(2)(D) of the Act defines an 
``urban area'' as an area within a MSA as defined by the Office of 
Management and Budget. The same

[[Page 39885]]

provision defines a ``large urban area,'' with respect to any fiscal 
year, as an urban area that the Secretary determines (in the 
publications described in section 1886(e)(5) of the Act before the 
fiscal year) has a population of more than 1 million as determined 
based on the most recent available published Census Bureau data. 
Section 1886(d)(2)(D) of the Act further defines a ``rural area'' as an 
area that is outside of a ``large'' urban area or ``other'' urban area. 
Since FY 1995, the average standardized amount for hospitals located in 
rural areas and ``other'' urban areas has been equal, as provided for 
in section 1886(b)(3)(B)(i)(X) of the Act.
    Several provisions of the Act provide procedures under which a 
hospital can apply for reclassification from one geographic area to 
another. Section 1886(d)(8)(B) of the Act, which provides that if 
certain conditions are met, the Secretary shall treat a hospital 
located in a rural county adjacent to one or more urban areas as being 
located in the urban area to which the greatest number of workers in 
the county commute. Also, section 1886(d)(10) of the Act established 
the MGCRB to permit hospitals that are disadvantaged by their 
geographic classification to obtain a more appropriate classification 
to the area with which they have the most economic interaction.
    In the August 1, 2000 interim final rule with comment period (65 FR 
47029), we implemented section 401(a) of Public Law 106-113. Section 
401(a) of Public Law 106-113, which amended section 1886(d)(8) by 
adding a new paragraph (E), directs the Secretary to treat any 
subsection (d) hospital located in an urban area as being located in 
the rural area of the State in which the hospital is located if the 
hospital files an application (in the form and manner determined by the 
Secretary) and meets one of the following criteria:
     The hospital is located in a rural census tract of an MSA 
(as determined under the most recent modification of the Goldsmith 
Modification, originally published in the Federal Register on February 
27, 1992 (57 FR 6725));
     The hospital is located in an area designated by any law 
or regulation of the State as a rural area (or is designated by the 
State as a rural hospital);
     The hospital would qualify as a rural referral center, or 
as an SCH if the hospital were located in a rural area; or
     The hospital meets any other criteria specified by the 
Secretary.
    The statutory effective date of this provision is January 1, 2000.
    In the August 1, 2000 interim final rule with comment period, we 
provided a detailed discussion of the development of the Goldsmith 
Modifications (65 FR 47029). The Goldsmith Modification evolved from an 
outreach grant program sponsored by the Office of Rural Health Policy 
of the Health Resources and Services Administration (HRSA) in order to 
establish an operational definition of rural populations lacking easy 
geographic access to health services. Using 1980 census data, Dr. 
Harold F. Goldsmith and his associates created a methodology for 
identification of rural census tracts that were located within a large 
metropolitan county of at least 1,225 miles but were so isolated from 
the metropolitan core by distance or physical features so as to be more 
rural than urban in character. We utilize data based on 1990 census 
data, reflecting the most recent Goldsmith modification.
    We also included Appendix A of that interim final rule with comment 
period a listing of the identified urban counties with census tracts 
that may qualify as rural under the most recent Goldsmith Modification 
(January 1, 2000). The amendments made by section 401 of Public Law 
106-113 enable a hospital located in one of the areas listed in 
Appendix A of the August 1, 2000 interim final rule with comment period 
to be treated as if it were situated in the rural area of the State in 
which it is located.
    Additionally, section 401(a) of Public Law 106-113 includes 
hospitals ``* * * located in an area designated by any law or 
regulation of such State as a rural area (or is designated by such 
State as a rural hospital).'' Since the concept of State 
``designation'' referred to in the parenthetical clause was not 
explicit enough to provide a clear-cut rule for purposes of 
implementation, we required that a hospital's designation as rural be 
in the form of either State law or regulation if it is the basis for a 
hospital's request for urban to rural reclassification. We believe this 
will help ensure that the provision is implemented consistently among 
States.
    Finally, a hospital also may seek to qualify for reclassification 
premised on the fact that, had it been located in a rural area, it 
would have qualified as a rural referral center or as an SCH. The 
hospital would need to satisfy the criteria set forth in section 
1886(d)(5)(C) of the Act (as implemented in regulations at Sec. 412.96) 
as a rural referral center, or the criteria set forth in section 
1886(d)(5)(D) of the Act (as implemented in regulations at Sec. 412.92) 
as an SCH.
    Although the statute authorizes the Secretary to specify further 
qualifying criteria for a section 401 reclassification, we did not 
believe that additional criteria were warranted at the time the August 
1, 2002 interim final rule was published. However, we invited comment 
specifically on whether the criteria in the interim final rule are 
sufficient at this time, and if not, what additional criteria should be 
incorporated.
    A hospital that is reclassified as rural under section 
1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-
113, is treated as rural for all purposes of payment under the Medicare 
inpatient hospital prospective payment system (section 1886(d) of the 
Act), including standardized amount (Secs. 412.60 et seq.), wage index 
(Sec. 412.63), and the DSH payment adjustment calculations 
(Sec. 412.106) as of the effective date of the reclassification.
    Comment: One commenter addressed policies discussed in the August 
1, 2000 interim final rule with comment period. Other commenters 
addressed our policy to not permit hospitals that are redesignated as 
rural under section 1886(d)(8)(E) of the Act to be eligible for 
subsequent reclassifications by the MGCRB.
    Response: These policies were addressed in the May 5, 2000 proposed 
rule (65 FR 26308) and the August 1, 2000 final rule (65 FR 47087) 
implementing the updates and policy changes to the prospective payment 
system for FY 2001. We responded to comments on the May 5, 2000 
proposed rule in the August 1, 2000 final rule. Because we addressed 
these concerns in that final rule, we are not readdressing those 
comments in this final rule.
    Comment: An association of physicians commented that the interim 
final rule with comment period stated that a hospital that is 
reclassified as rural under this provision must be treated as rural for 
all purposes of payment under the Medicare inpatient hospital 
prospective payment system, including standardized amount, wage index, 
and the DSH payment adjustment. However, the commenter pointed out, 
graduate medical education is not listed. The commenter urged that 
these hospitals also be considered rural for purposes of graduate 
medical education.
    Response: Section 1886(d)(8)(E) of the Act provides that affected 
hospitals are considered rural for purposes of section 1886(d). 
Therefore, these reclassifications affect payments to a hospital under 
the IME adjustment, which are made under section 1886(d)(5)(B) of the 
Act, but not payments for direct GME, which are made under section 
1886(h) of the Act.

[[Page 39886]]

2. Conforming Changes under Section 401(b) of Public Law 106-113
    Section 401(b) of Public Law 106-113 sets forth conforming 
statutory changes relating to urban to rural reclassifications under 
section 401(a) of Public Law 106-113:
     Section 401(b)(1) provided that if a hospital is being 
treated as being located in a rural area under section 1886(d)(8)(E) of 
the Act (for purposes of section 1886(d) of the Act), the hospital will 
also be treated under section 1833(t) of the Act as being located in a 
rural area. This provision was addressed in the final rule for the 
hospital inpatient prospective payment system published in the Federal 
Register on August 1, 2000 (65 FR 47087).
     Section 401(b)(2) amended section 1820(c)(2)(B)(i) of the 
Act by extending the reclassification provisions of section 401(a) to 
the CAH program. A hospital that otherwise would have fulfilled the 
requirements for designation as a CAH had it been located in a rural 
area is now eligible for consideration as a CAH if it is treated as 
being located in a rural area under section 1886(d)(8)(E) of the Act, 
as added by section 401(a) of Public Law 106-113. (A list of certain 
existing hospitals that were identified as being located in Goldsmith 
areas was included in Appendix B of the August 1, 2000 interim final 
rule with comment period.) A more detailed discussion of the effect on 
the CAH program of this provision, as well as additional amendments to 
section 1820(c)(2)(B)(i) of the Act included in Public Law 106-113, is 
provided in section VI.B. of this preamble.
3. Application Procedures
    The statute provides that a hospital seeking reclassification from 
urban to rural under section 1886(d)(8)(E) of the Act must submit an 
application ``in a form and manner determined by the Secretary.'' In 
the August 1, 2000 interim final rule with comment period, we set forth 
procedures and requirements for the application for rural 
reclassification, including application submittal requirements, the 
filing and effective dates for the application, the procedures for 
withdrawal of applications, and cancellation of rural reclassification; 
and the qualifications through the Goldsmith Modification Criteria, by 
State designation and qualifications as a rural referral center or as 
an SCH. (See 65 FR 47030 through 47031 for a full discussion of these 
procedures and requirements.) As of early July 2001, 19 hospitals had 
taken advantage of this provision.
4. Changes in the Regulations
    In the August 1, 2000 interim final rule with comment period, we 
added a new Sec. 412.103 to incorporate the provisions on the urban to 
rural reclassification options set forth in section 1886(d)(8)(E) of 
the Act, as added by section 401(a) of Public Law 106-113, and the 
application procedures for requesting reclassification.
    A formula for transition payments to hospitals located in an area 
that has undergone geographic reclassification from urban to rural is 
set forth in section 1886(d)(8)(A) of the Act and implemented in 
regulations at Secs. 412.90 and 412.102. In the interim final rule with 
comment period, we revised existing Secs. 412.63(b)(1) and 412.90(e) 
and the title of Sec. 412.102 to clarify the distinction between 
hospital reclassification from urban to rural and the geographic 
reclassification (or redesignation) of an urban area to rural.
    In addition, we revised Sec. 485.610 by redesignating paragraph 
(b)(4) as paragraph (b)(5) and adding a new paragraph (b)(4) to reflect 
the conforming provision of section 401(b)(2) of Public Law 106-113.
    We did not receive any comments on these changes in the regulations 
in the interim final rule with comment period and, therefore, are 
adopting them as final.

G. Medicare Geographic Classification Review Board (MGCRB) (New 
Sec. 412.235 and Existing Secs. 412.256, 412.273, 412.274(b), and 
412.276)

    With the creation of the MGCRB, beginning in FY 1991, under section 
1886(d)(10) of the Act, hospitals could request reclassification from 
one geographic location to another for the purpose of using the other 
area's standardized amount for inpatient operating costs or the wage 
index value, or both (September 6, 1990 interim final rule with comment 
period (55 FR 36754), June 4, 1991 final rule with comment period (56 
FR 25458), and June 4, 1992 proposed rule (57 FR 23631)). Implementing 
regulations in Subpart L of Part 412 (Secs. 412.230 et seq.) set forth 
criteria and conditions for redesignations from rural to urban, rural 
to rural, or from an urban area to another urban area with special 
rules for SCHs and rural referral centers.
    As discussed in section III.F. of this final rule, section 304 of 
Public Law 106-554 contained several provisions related to the wage 
index and reclassification decisions made by the MGCRB. In summary, 
section 304 first establishes that hospital reclassification decisions 
by the MGCRB for wage index purposes are effective for 3 years, 
beginning with reclassifications for FY 2001. Second, it provides that 
the MGCRB must use the 3 most recent years of average hourly wage data 
in evaluating a hospital's reclassification application for FY 2003 and 
subsequent years. Third, it provides that an appropriate statewide 
entity may apply to have all of the geographic areas in a State treated 
as a single geographic area for purposes of computing and applying the 
wage index, for reclassifications beginning in FY 2003. In the May 4, 
2001 proposed rule, we presented a discussion of how we proposed to 
implement these three provisions. (Section III.F. of this preamble 
discusses the application of these policy changes to the development of 
the final FY 2002 and later wage indexes based on hospital 
reclassification under the provisions of section 304 of Public Law 106-
554.)
1. Three-Year Reclassifications for Wage Index Purposes
    Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) 
of the Act by adding clause (v), which provides that, if a hospital is 
approved for reclassification by the MGCRB for purposes of the wage 
index, the reclassification is effective for 3 years. The amendment 
made by section 304(a) is effective for reclassifications for FY 2001 
and subsequent years. In addition, the legislation specifies that the 
Secretary must establish a mechanism under which a hospital may elect 
to terminate such reclassification during the 3-year period.
    Consistent with new section 1886(d)(10)(D)(v) of the Act, in the 
May 4 proposed rule, we proposed to revise Sec. 412.274(b) to provide 
under new paragraph (b)(2) that any hospital that is reclassified for a 
particular fiscal year for purposes of receiving the wage index value 
of another area would receive that reclassification for 3 years 
beginning with discharges occurring on the first day (October 1) of the 
second Federal fiscal year in which a hospital files a complete 
application. This 3-year reclassification would remain in effect unless 
the hospital terminates the reclassification under revised procedures 
that we proposed to establish under new proposed Sec. 412.273(b). The 
provision would apply to hospitals that are reclassified for purposes 
of the wage index only, as well as those that are reclassified for both 
the wage index and the standardized amount. However, in the latter 
case, only the wage index reclassification would be extended for 2 
additional

[[Page 39887]]

years beyond the 1 year provided for in the existing regulations (3 
years total). Hospitals seeking reclassification for purposes of the 
standardized amount must continue to reapply to the MGCRB on an annual 
basis.
a. Special Rule for a Hospital that was Reclassified for FY 2001 and FY 
2002 to Different Areas
    Because the 3-year effect of the amendment made by section 304(a) 
of Public Law 106-554 is applicable to reclassifications for FY 2001 
(which had already taken place prior to the date of enactment of 
section 304(a) (December 21, 2000)), and because the application 
process for reclassifications for FY 2002 had already been completed by 
the date of enactment, we are establishing special procedures for 
hospitals that are reclassified for purposes of the wage index to one 
area for FY 2001, and are reclassified for purposes of the wage index 
or the standardized amount to another area for FY 2002. We are deeming 
such a hospital to be reclassified to the area for which it applied for 
FY 2002, unless the hospital elects to receive the wage index 
reclassification it was granted for FY 2001. Consistent with our 
procedures for withdrawing an application for reclassification 
(Sec. 412.273), we allowed a hospital that wished to receive the 
reclassification it was granted for FY 2001 to withdraw its FY 2002 
application by making a written request to the MGCRB within 45 days of 
the publication date of the proposed rule (that is, by June 18, 2001). 
Again, only the wage index reclassification is extended for 2 
additional years (3 years total). Hospitals seeking reclassification 
for purposes of the standardized amount must continue to reapply to the 
MGCRB on an annual basis.
    (We note that, effective May 21, 2001, the new location and mailing 
address of the MGCRB and the Provider Reimbursement Review Board (PRRB) 
is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. 
Please specify whether the mail is intended for the MGCRB or the PRRB.)
b. Overlapping Reclassifications Are Not Permitted
    Under the broad authority delegated to the Secretary by section 
1886(d)(10) of the Act, in the May 4 proposed rule, we proposed that a 
hospital that is reclassified to an area for purposes of the wage index 
may not extend the 3-year effect of the reclassification under section 
304(a) of Public Law 106-554 by subsequently applying for 
reclassification to the same area for purposes of the wage index for a 
fiscal year that would be within the 3-year period. For example, if a 
hospital is reclassified for purposes of the wage index to Area A for 
FY 2002, is approved to receive Area A's wage index for 3 years (FYs 
2002, 2003, and 2004), and reapplies to be reclassified to Area A for 
FYs 2003, 2004, and 2005 (3 years) for purposes of the wage index, the 
hospital would not be permitted to receive Area A's wage index for FY 
2005 as a result of the reapplication. Instead, we proposed that if the 
hospital wishes to extend the FY 2002 3-year reclassification for 
fiscal years beyond FY 2004, it would have to apply for 
reclassification for FY 2005.
    We believe new section 1886(d)(10)(D)(v) of the Act replaces the 
current annual wage index reclassification cycle with a 3-year 
reclassification cycle. We believe this policy was intended to provide 
consistency and predictability in hospital reclassification and wage 
index data, as well as to alleviate the year-to-year fluctuations in 
the ability of some hospitals to qualify for reclassification. We do 
not believe it was intended to be used to extend reclassifications for 
which hospitals otherwise would not be eligible (by reapplying during 
the second year of a 3-year reclassification because a hospital fears 
it may not be eligible for reclassification after its current 3-year 
reclassification expires).
c. Withdrawals of Applications and Terminations of Approved 
Reclassifications
(1) General
    Under Sec. 412.273(a), a hospital, or group of hospitals, may 
withdraw its application for reclassification at any time before the 
MGCRB issues its decision or, if after the MGCRB issues its decision, 
within 45 days of publication of our annual notice of proposed 
rulemaking concerning changes to the inpatient hospital prospective 
payment system and proposed payment rates for the fiscal year for which 
the application was filed. In the May 4 proposed rule, we proposed that 
the withdrawal procedures and the applicable timeframes in the existing 
regulations would apply to hospitals that would receive 3-year 
reclassification for wage index purposes. For example, if a hospital 
applied for reclassification to Area A for purposes of the wage index 
for FY 2002, but wished to withdraw its application, it must have done 
so prior to the MGCRB issuing a decision on its application or, if the 
MGCRB issued such a decision, within 45 days of the publication date of 
the proposed rule (that is, by June 18, 2001). Such a withdrawal, if 
effective, means that the hospital would not be reclassified to Area A 
for purposes of the wage index for FY 2002 (and would not receive 
continued reclassification for FYs 2003 and 2004), unless the hospital 
subsequently cancels its withdrawal (as discussed below). In other 
words, a withdrawal, if accepted, prevents a reclassification from ever 
becoming effective.
    On the other hand, a reclassification decision that is terminated 
upon the request of the hospital has partial effect. Section 
1886(d)(10)(D)(v) of the Act, as added by section 304(a) of Public Law 
106-554, provides that a reclassification for purposes of the wage 
index is effective for 3 years ``except that the Secretary shall 
establish procedures under which a . . . hospital may elect to 
terminate such reclassification before the end of such period.'' 
Consistent with section 1886(d)(10)(D)(v) of the Act, we proposed to 
allow a hospital to terminate its approved 3-year reclassification for 
1 or 2 years of the 3-year effective period (Sec. 412.273(b)). This is 
a separate action from a reclassification withdrawal, which occurs 
following the initial decision by the MGCRB. A termination would occur 
during subsequent years. For example, a hospital that has been 
reclassified for purposes of the wage index for FY 2001 is also 
reclassified for FYs 2002 and 2003 (3 years). Such a hospital could 
terminate its approved reclassification so that the reclassification is 
effective only for FY 2001, or only for FYs 2001 and 2002. Consistent 
with the prospective nature of reclassifications, we proposed to not 
permit a hospital to terminate its approved 3-year reclassification for 
part of a fiscal year. A termination would be effective for the next 
fiscal year. In order to terminate an approved 3-year reclassification, 
we would require the hospital to notify the MGCRB in writing within 45 
days of the publication date of the annual proposed rule for changes to 
the inpatient hospital prospective payment system. A termination, 
unless subsequently cancelled (as discussed below), is effective for 
the balance of the 3-year period.
    We established a special procedural rule for handling FY 2001 
reclassifications. As noted above, the amendments made by section 
304(a) of Public Law 106-554 are effective for reclassifications for 
FYs 2001 and beyond, and reclassification decisions for FY 2001 had 
already been implemented prior to the date of enactment of section 
304(a). We deemed those hospitals that were reclassified for

[[Page 39888]]

FY 2001 to be reclassified for FYs 2002 and 2003. Therefore, if a 
deemed hospital that was reclassified for purposes of the wage index 
for FY 2001 wished to terminate its reclassification for FY 2002 and FY 
2003, the hospital had to notify the MGCRB in writing by June 18, 2001 
(that is, within 45 days after the publication of the proposed rule).
(2) Cancellation of a Withdrawal of Application or a Termination of an 
Approved Reclassification
    In the May 4 proposed rule, we proposed that if a hospital elects 
to withdraw its 3-year reclassification application after the MGCRB has 
issued its decision, it may cancel its withdrawal in a subsequent 
fiscal year and request the MGCRB to reinstate its reclassification for 
the remaining fiscal years of the 3-year reclassification period. (This 
proposal was consistent with our proposal that 3-year reclassification 
periods may not overlap, as discussed in section IV.G.1.b. of this 
preamble.) Alternatively, a hospital may apply for reclassification to 
a different area (that is, an area different from the one to which it 
was originally reclassified), and if successful, the reclassification 
effect would be for 3 years.
    Similarly, and for the same reasons, we proposed that if a hospital 
elects to terminate its accepted 3-year reclassification prior to the 
second or third year of that reclassification, it may cancel that 
termination and have its original reclassification reinstated for the 
duration of the original 3-year period. Alternatively, a hospital could 
apply for reclassification to a different area after terminating a 
prior 3-year reclassification and receive a new 3-year period of 
reclassification.
    Example 1: Hospital A files an application and the MGCRB issues 
a decision to reclassify it to Area B for purposes of wage index for 
FY 2002 through FY 2004 (3 years). Within 45 days after the 
publication of the proposed rule, Hospital A withdraws its 
application. Within the time for applying for a FY 2003 
reclassification, Hospital A cancels its withdrawal for 
classification to Area B. Its reclassification to Area B is 
reinstated, but only for FYs 2003 and 2004.
    Example 2: Hospital B files an application for reclassification 
for wage index purposes for FY 2002 through FY 2004 and the MGCRB 
issues a decision for reclassification to Area C. Within 45 days 
after publication of the proposed rule, Hospital B withdraws its 
application. Hospital B does not cancel its withdrawal of the 
application. Hospital B timely applies and is reclassified to Area D 
for 3 years, beginning with FY 2003. In this case, the 
reclassification to Area D would be for FYs 2003 through 2005.
    Example 3: Hospital C is reclassified to Area A for purposes of 
the wage index for FY 2002, and terminates its 3-year 
reclassification effective for FYs 2003 and 2004. Within the 
timeframe for applying for FY 2004 reclassification, Hospital C 
cancels its termination. Its reclassification to Area A would be 
reinstated for FY 2004 only.
    Example 4: Hospital D has the same circumstances as Hospital C 
in Example 3, except that instead of canceling its termination, 
Hospital D applies and is reclassified to Area B for FY 2004. In 
this case, the reclassification would be for FYs 2004 through 2006.

d. Special Rules for Group Reclassifications
    Section 412.232 discusses situations where all hospitals in a rural 
county are seeking urban redesignation, and Sec. 412.234 discusses 
criteria where all hospitals in an urban county are seeking 
redesignation to another urban county. In these cases, hospitals submit 
an application as a group, and all hospitals in the county must be a 
party to the application. The reclassification is effective both for 
purposes of the wage index and the standardized amount of the area to 
which the hospitals are reclassified.
    Section 304(a) of Public Law 106-554 does not specifically address 
the group reclassification situations under Secs. 412.232 and 412.234. 
However, we believe that, in the case of hospitals reclassified under 
these group reclassification procedures, it would be appropriate to 
extend the 3-year reclassification provision to these situations for 
the wage index only. In order to be reclassified for the standardized 
amount during the second and third years of a 3-year reclassification 
for the wage index, the hospitals located in these counties would have 
to reapply on an annual basis to the MGCRB either as a group or as 
individual hospitals and meet the criteria outlined in Sec. 412.232, 
Sec. 412.234, or Sec. 412.230, as appropriate.
    Hospitals that are part of a group reclassification would be able 
to terminate their 3-year wage index reclassifications in the same 
manner as described above. If one hospital within the group elects to 
terminate its 3-year wage index reclassification, the reclassification 
of other hospitals in the group would be unaffected. The same rules for 
withdrawing from a group reclassification that are in effect now would 
continue. That is, all of the hospitals that are party to a group 
reclassification application must consent for a withdrawal to be 
approved.
    Under section 152(b) of Public Law 106-113, hospitals in certain 
counties were deemed to be located in specified areas for purposes of 
payment under the hospital inpatient prospective payment system, for 
discharges occurring on or after October 1, 2000. For payment purposes, 
these hospitals are to be treated as though they were reclassified for 
purposes of both the standardized amount and the wage index. Section 
152(b) also requires that these reclassifications be treated for FY 
2001 as though they are reclassification decisions by the MGCRB. For 
purposes of applying the 3-year extension of wage index 
reclassifications, we proposed to extend section 1886(d)(10)(D)(v) to 
hospitals reclassified under section 152(b) of Public Law 106-113. 
These hospitals also would have to apply for the standardized amount on 
an annual basis to the MGCRB.
e. Administrator Authority to Cancel Inappropriate Reclassification 
Decisions
    In the proposed rule we indicated that, under the provisions of 
Sec. 412.278(g), the Administrator has the authority to review an 
inappropriate reclassification decision made by the MGCRB, as 
discovered by either the hospital or CMS, including 3-year 
reclassifications in the second and third years. The statement that 
this authority extended to the second and third years of 3-year 
reclassification was in error. Under the statute and our regulations, 
reclassification decisions are unreviewable once they become final. 
This principle applies to 3-year reclassification decisions. Once such 
a decision becomes final, it is unreviewable thereafter.
    Comment: Several commenters expressed concern that we proposed that 
a hospital that is reclassified to an area for purposes of the wage 
index may not extend the 3-year effect of the reclassification under 
section 304(a) of Public Law 106-554, by subsequently applying for 
reclassification to the same area for purposes of the wage index for a 
fiscal year that would be within the 3-year period. These commenters 
argued that there is nothing in the statutory language that prohibits 
hospitals that are already approved for 3-year reclassifications from 
reapplying within that 3-year period to extend their reclassifications 
into future years. These commenters also pointed out that extending 
their wage index reclassifications in this way allows them to make 
budgetary commitments further into the future and fosters a more stable 
operating environment for their hospitals.
    Response: Under section 1886(d)(10) of the Act, the Secretary has 
broad authority to establish policies and

[[Page 39889]]

criteria with respect to the evaluation and approval of applications 
for reclassification. As indicated in the proposed rule, we believe 
that new section 1886(d)(10)(D)(v) of the Act, as added by section 
304(a) of Public Law 106-554, replaces the annual reclassification 
cycle with a 3-year reclassification cycle. We believe that, if a 
hospital is already reclassified to a given geographic area for a 3-
year period, it is appropriate to avoid expending resources to evaluate 
an application for reclassification to that same area for the second 
and third years of the 3-year period. Thus, if a hospital is already 
reclassified for a given fiscal year, and submits an application for 
reclassification to the same area for the same year, that application 
will not be approved. We are adding language to Sec. 412.230(a)(5)(v) 
in this final rule to specify that an application for reclassification 
will not be approved under these circumstances.
    Comment: One commenter supported our proposal to reclassify a 
hospital based on its FY 2002 approval unless the hospital notified the 
MGCRB otherwise by June 18, 2001. This commenter questioned whether or 
not hospitals would have this same option in future years. In other 
words, if a hospital successfully sought reclassification to a 
different area for FY 2003 and then withdrew that reclassification, 
would that hospital have the option to fall back on the FY 2002 
reclassification, or would it then not be reclassified.
    Response: We appreciate the commenter's support of our proposal on 
this issue. This was specifically put in place because the new 3-year 
reclassification policy was not enacted until well after the 
reclassification process for FY 2002 was underway. Therefore, some 
hospitals may have sought reclassification to a different area or for a 
different purpose than they did for FY 2001, and the option to carry 
forward a FY 2001 wage index reclassification for 3 years may have 
changed their decisions.
    This policy applies in future years as well. For example, a 
hospital that successfully seeks reclassification for the wage index 
for FY 2004 to Area A, then successfully seeks reclassification for FY 
2005 for the wage index to Area B, has the option to withdraw its FY 
2005 decision, thereby reinstating its FY 2004 decision. However, if 
the hospital successfully withdraws its FY 2005 decision, the hospital 
cannot return to its FY 2005 decision without reapplying at a later 
date.
    Comment: Several commenters expressed uncertainty about the timing 
of the extension of the wage index reclassification for 3 years. Some 
hospitals had successfully applied for FY 2001 as well as FY 2002 to 
the same area for the wage index, and it was not clear to these 
hospitals whether their wage index reclassifications were effective 
through FY 2003 or through FY 2004.
    Response: As noted above, section 304(a) provides for 3-year wage 
index reclassifications effective with FY 2001 reclassifications. In 
the case of hospitals reclassified to the same area for both FY 2001 
and FY 2002, because hospitals had already submitted their FY 2002 
applications prior to enactment of Public Law 106-554, and the MGCRB 
had already issued its decision on these applications prior to 
publication of the May 4 proposed rule, we will consider FY 2002 to be 
the first year of the 3-year reclassification for these hospitals. 
Therefore, the reclassification period will extend through FY 2004. If 
a hospital was approved for FY 2001 for a wage index reclassification, 
but was unsuccessful in seeking a wage index reclassification for FY 
2002, then its wage index reclassification would be effective for FY 
2001, FY 2002, and FY 2003, and the hospital would have to reapply to 
seek reclassification for FY 2004.
    Comment: One commenter supported our proposal that a hospital could 
cancel its withdrawal of an approved reclassification for the wage 
index in a future year in order to reinstate its original MGCRB 
approval.
    Response: We appreciate the commenter's support of our proposal 
that hospitals reclassified for the wage index that then withdraw that 
approval have the ability to cancel the withdrawal, in effect 
reinstating the hospital's original reclassification approval for the 
wage index. We provided this option so that a hospital that later 
discovers that the withdrawal of its approved wage index 
reclassification was disadvantageous would have the ability to 
reinstate its MGCRB approval for the wage index for the remaining years 
in the 3-year term. However, a hospital is eligible to revert to its 
most recent MGCRB approval only.
    In addition, the same process applies to cancellations of a 
withdrawal or termination as applies to requests for withdrawals and 
terminations. A hospital must request a cancellation of its withdrawal 
or termination within the 45-day period after the proposed rule is 
published, and that cancellation will become effective for the 
following Federal fiscal year.
    Comment: Several commenters supported our proposal to extend the 3-
year reclassification provision for the wage index to those hospitals 
that were reclassified for FY 2001 under section 152(b) of Public Law 
106-113. While these hospitals did not successfully apply for 
reclassification through the MGCRB, they were effectively 
``reclassified'' by this legislation, and the commenters believed that 
it would be correct to extend the 3-year wage index reclassification to 
this group of hospitals.
    Response: We appreciate the commenters' support of our proposal. 
Section 152(b) of Public Law 106-113 required that the assignment of 
these hospitals to alternative geographic areas should be treated as if 
they were decisions of the MGCRB. As a result, these hospitals will be 
reclassified for the wage index to their designated areas for FY 2002 
and FY 2003. They will be required to apply for reclassification to the 
MGCRB for FY 2004 if they wish to retain this reclassification for 
subsequent years.
2. Three-Year Average Hourly Wages
    Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) 
of the Act by adding clause (vi) which provides that the MGCRB must use 
the average of the 3 most recent years of hourly wage data for the 
hospital when evaluating a hospital's request for reclassification. 
Specifically, the MGCRB must base its evaluation on an average of the 
average hourly wage for the most recent years for the hospital seeking 
reclassification and the area to which the hospital seeks to 
reclassify. This provision is effective for reclassifications for FY 
2003 and subsequent years. (Section III.F. of this preamble discusses 
the development and application of the hospital's 3-year average hourly 
wage data (Table 2 in the Addendum to this final rule) that the MGCRB 
will use to evaluate hospitals' applications for reclassifications for 
FY 2003; and the MSA and statewide rural 3-year average hourly wage 
data (Tables 3A and 3B in the Addendum to this final rule) for hospital 
reclassification applications for FY 2003.)
    In the May 4, 2001 proposed rule, we proposed to revise 
Secs. 412.230(e)(2) and 412.232(d)(2) to incorporate the provisions of 
section 1886(d)(10)(D)(vi) of the Act as added by section 304(a) of 
Public Law 106-554. Specifically, we provided that, for redesignations 
effective beginning FY 2003, for hospital-specific data, the hospital 
must provide a 3-year average of its average hourly wages using data 
from our hospital wage survey used to construct

[[Page 39890]]

the wage index in effect for prospective payment purposes. For data for 
other hospitals, we proposed to require hospitals to provide a 3-year 
average of the average hourly wage in the area in which the hospital is 
located and a 3-year average of the average hourly wage in the area to 
which the hospital seeks reclassification. The wage data would be taken 
from the CMS hospital wage survey used to construct the wage index for 
prospective payment purposes, as published in Tables 2, 3A, and 3B of 
this final rule (unless those data are subsequently changed by CMS). 
The 3-year averages are calculated by dividing the sum of the dollars 
(adjusted to a common reporting period using the method described in 
section III. of this final rule) across all 3 years, by the sum of the 
hours.
    Comment: Several commenters responded positively to our proposal to 
use a 3-year average of the most recent 3 years of average hourly wages 
based on data from our hospital wage survey used to construct the wage 
index when evaluating a hospital's request for reclassification. Under 
the proposal, if data does not exist for all 3 years, the available 
data within the 3-year period will be used to construct the average.
    While it was clear to these commenters that these data will be used 
to construct the average hourly wage for a hospital applying for 
reclassification, they noted it was not clear to them whether the 3-
year average would also be used for the area in which that hospital is 
physically located as well as the area to which that hospital seeks 
reclassification.
    Response: We appreciate the commenters' support of our proposal to 
calculate the 3-year average hourly wage based on the data available 
during the applicable 3-year period, even if a hospital does not have 
data in all 3 years.
    As noted above, the MGCRB will evaluate applications using the 3-
year average hourly wages for hospitals and geographic areas as 
published in Tables 2, 3A, and 3B of this final rule (unless those data 
are subsequently changed by CMS).
    Comment: One commenter requested that in cases of a change in 
ownership, a hospital be permitted the option of excluding prior years' 
wage data submitted by a previous owner for the purpose of calculating 
the average of the average hourly wages in order to qualify for 
reclassification. As a result, the average of the average hourly wages 
would be based on current and prior year data submitted by the new 
owner only.
    Response: We believe we should treat these cases in a manner 
consistent with how we treat hospitals whose ownership has changed for 
other Medicare payment purposes. That is, where a hospital has simply 
changed ownership and the new owners have acquired the assets and 
liabilities of the previous owners, all of the applicable wage data 
associated with that hospital are included in the calculation of its 3-
year average hourly wage. On the other hand, in the case of a new 
hospital, where there is no legal obligation to the operations of a 
predecessor hospital, the wage data associated with the previous 
hospital's provider number would not be used in calculating the new 
hospital's 3-year average hourly wage.
3. Statewide Wage Index
    As stated earlier, section 304(b) of Public Law 106-554 provides 
for a process under which an appropriate statewide entity may apply to 
have all the geographic areas in the State treated as a single 
geographic area for purposes of computing and applying the area wage 
index for reclassifications beginning in FY 2003.
    Section 304 does not indicate the duration of the application of 
these statewide wage indexes. However, it should be noted that the 
statutory language does refer to these applications as 
reclassifications. In the May 4, 2001 proposed rule, we proposed that 
these statewide wage index applications be processed similar to MGCRB 
applications, with the same effective dates of the decisions and the 
withdrawal and termination process. Therefore, similar to wage index 
reclassification decisions under section 1886(d)(10)(D)(v) of the Act 
as added by section 304(a) of Public Law 106-554, the statewide wage 
index reclassification would be effective for a total of 3 years. The 
same deadlines and timetable applicable to MGCRB reclassification 
applications would apply for statewide wage index applications.
    We proposed to establish a new Sec. 412.235 to include the 
requirements for statewide wage indexes. We proposed to apply the 
following criteria to determine whether hospitals would be approved for 
a statewide geographic wage index reclassification (Sec. 412.235(a)):
     There must be unanimous support for a statewide wage index 
among hospitals in the State in which the statewide wage index would be 
applied. We would require a signed affidavit on behalf of all the 
hospitals in the State of this support as part of the application for 
reclassification.
     All hospitals in the State must apply through a signed 
single application for the statewide wage index in order for the 
application to be considered by the MGCRB. We believe this is necessary 
to ensure that every hospital in the State is included in the 
application, since the payment of every hospital would be affected by 
the statewide wage index.
     There must be unanimous support for the termination or 
withdrawal of a statewide wage index among hospitals in the State in 
which the statewide wage index would be applied. We would require a 
signed affidavit for this agreement.
     All hospitals in the State waive their rights to any wage 
index that they would otherwise receive absent the statewide wage 
index, including a wage index that any of the hospitals might have 
received through individual or group geographic reclassification under 
Sec. 412.273(a).
    An individual hospital within the State may receive a wage index 
that could be higher or lower under the statewide wage index 
reclassification in comparison to its wage index otherwise 
(Sec. 412.235(b)). Specifically, hospitals must be aware that there may 
be a reduction in the wage index as a result of participation on a 
statewide basis.
    In addition, we proposed to consider statewide wage index 
applications under the same process we use for hospital 
reclassification applications, including the effective dates of the 
MGCRB decision and the withdrawal and termination process 
(Sec. 412.235(c)). We proposed that applications for the statewide wage 
index would be effective for 3 years beginning with discharges 
occurring on the first day (October 1) of the second Federal fiscal 
year following the Federal fiscal year in which the hospitals file a 
complete application unless all of the participating hospitals withdraw 
their application or terminate their approved statewide wage index 
reclassification earlier, as discussed below. Once approved by the 
MGCRB, an application for a statewide wage index can only be withdrawn 
or terminated as a result of a signed affidavit on behalf of all the 
hospitals in the State indicating their request that the statewide 
reclassification be withdrawn or terminated. A request for withdrawal 
or termination must be submitted within 45 days of the publication of 
the annual proposed rule for the inpatient hospital prospective payment 
system announcing the reclassification. New hospitals that open prior 
to the September 1 deadline for submitting an application for a 
statewide wage index, but after a group

[[Page 39891]]

application has been submitted, would be required to agree to the 
statewide wage index in order for the group application to remain 
viable. New hospitals that open after the deadline for submitting an 
application would receive the statewide wage index. The agreement of 
new hospitals would also be required in order to withdraw or terminate 
a statewide wage index reclassification. The rules discussed under 
section IV.G.1.c. of this preamble for withdrawals of applications and 
terminations of approved 3-year wage index reclassification decisions 
would apply to decisions regarding statewide wage index 
reclassifications.
    Comment: Several commenters believed that Washington, DC should be 
recognized as a State for purposes of this statewide wage index 
reclassification policy. However, they were concerned that, while such 
a recognition may benefit hospitals located in Washington, DC, it may 
not benefit hospitals that are currently located outside of Washington, 
DC but within the Washington, D.C.-MD-VA-WV MSA. As a result, while 
these commenters believed that Washington, DC should be recognized as a 
State for this purpose, they also requested guidance about how the 
remainder of the hospitals in the current MSA would be treated.
    One commenter did not believe that Washington, DC should be 
considered a State for this purpose. However, this commenter also 
stated that, should we decide that Washington, DC could be considered a 
State for this purpose, we should configure the criteria such that none 
of the hospitals that are currently located in the Washington, D.C.-MD-
VA-WV MSA would be harmed.
    Response: Section 304(b) of Public Law 106-554 directs the 
Secretary to establish a process ``under which an appropriate statewide 
entity may apply to have all the geographic areas in a State treated as 
a single geographic area for purposes of computing and applying the 
area wage index under section 1886(d)(3)(E) of [the Social Security] 
Act. * * *'' Most States encompass multiple labor market areas (urban 
MSAs and rural areas) with differing wage indexes, and we believe that 
the intent of section 304(b) is to offer hospitals within a State the 
opportunity to eliminate the disparate wage indexes resulting from 
separate urban and rural labor market areas within the State. However, 
hospitals in Washington, DC are not subject to disparate wage indexes. 
Washington, DC is part of a larger labor market area where all the 
hospitals receive the wage index for that labor market area (subject to 
MGCRB reclassifications). Put another way, Washington, DC is already 
``treated as a single geographic area'' for purposes of the hospital 
wage index.
    If we treated Washington, DC as a separate distinct labor market 
area and applied the usual wage index methodology, Washington, DC 
hospitals might reap a significant windfall and the hospitals remaining 
in the MSA might be disadvantaged. Given the intended purpose of 
section 304(b), we believe that such results would be inappropriate. We 
believe that Congress did not intend for section 304(b) to address the 
type of situation presented by Washington, DC.
    As indicated above, section 304(b) permits a State to be treated as 
a single geographic area ``for purposes of computing and applying the 
area wage index under section 1886(d)(3)(E) of [the] Act.'' Section 
304(b) does not specify how to compute and apply the wage index for 
statewide geographic areas. Under section 1886(d)(3)(E) of the Act, the 
Secretary has broad authority to develop and apply the methodology for 
determining the wage index for labor market areas, and section 304(b) 
did not limit the agency's authority. Thus, even if Washington, DC is a 
State for purposes of section 304(b), the Secretary has broad authority 
under section 1886(d)(3)(E) to determine the wage index for all 
affected hospitals. Given the purpose of section 304, and to avoid 
conferring an inappropriate and unintended windfall (or disadvantage) 
to hospitals, we are providing (pursuant to our broad authority under 
section 1886(d)(3)(E) of the Act) that, even if Washington, DC is a 
State for purposes of section 304(b) of Public Law 106-554, the wage 
index applicable to the Washington, DC ``statewide'' geographic area 
would be the same wage index that would apply to the Washington, DC-MD-
VA-WV MSA as a whole (which would be calculated by including 
Washington, DC hospitals, in accordance with all applicable rules).

H. Payment for Direct Costs of Graduate Medical Education (Sec. 413.86)

1. Background
    Under section 1886(h) of the Act, Medicare pays hospitals for the 
direct costs of graduate medical education (GME). The payments are 
based in part on the number of residents trained by the hospital. 
Section 1886(h) of the Act, as amended by section 4623 of Public Law 
105-33, caps the number of residents that hospitals may count for 
direct GME.
    Section 1886(h)(2) of the Act, as amended by section 9202 of the 
Consolidated Omnibus Reconciliation Act (COBRA) of 1985 (Public Law 99-
272), and implemented in regulations at Sec. 413.86(e), establishes a 
methodology for determining payments to hospitals for the costs of 
approved GME programs. Section 1886(h)(2) of the Act, as amended by 
COBRA, sets forth a payment methodology for the determination of a 
hospital-specific, base-period per resident amount (PRA) that is 
calculated by dividing a hospital's allowable costs of GME for a base 
period by its number of residents in the base period. The base period 
is, for most hospitals, the hospital's cost reporting period beginning 
in FY 1984 (that is, the period of October 1, 1983 through September 
30, 1984). The PRA is multiplied by the number of FTE residents working 
in all areas of the hospital complex (or nonhospital sites, when 
applicable), and the hospital's Medicare share of total inpatient days 
to determine Medicare's direct GME payments. In addition, as specified 
in section 1886(h)(2)(D)(ii) of the Act, for cost reporting periods 
beginning on or after October 1, 1993, through September 30, 1995, each 
hospital's PRA for the previous cost reporting period is not updated 
for inflation for any FTE residents who are not either a primary care 
or an obstetrics and gynecology resident. As a result, hospitals with 
both primary care and obstetrics and gynecology residents and 
nonprimary care residents have two separate PRAs beginning in FY 1994: 
one for primary care and obstetrics and gynecology and one for 
nonprimary care.
    Section 1886(h)(2) of the Act was further amended by section 311 of 
Public Law 106-113 to establish a methodology for the use of a national 
average PRA in computing direct GME payments for cost reporting periods 
beginning on or after October 1, 2000, and on or before September 30, 
2005. Generally, section 1886(h)(2) of the Act establishes a ``floor'' 
and a ``ceiling'' based on a locality-adjusted, updated, weighted 
average PRA. Each hospital's PRA is compared to the floor and ceiling 
to determine whether its PRA should be revised. PRAs that are below the 
floor, that is, 70 percent of the locality-adjusted, updated, weighted 
average PRA, would be revised to equal 70 percent of the locality-
adjusted, updated, weighted average PRA. PRAs that exceed the ceiling, 
that is, 140 percent of the locality-adjusted, updated, weighted 
average PRA, would, depending on the fiscal year, either be frozen and 
not increased for inflation, or increased by a reduced inflation 
factor.

[[Page 39892]]

We implemented section 311 of Public Law 106-113 in the hospital 
inpatient prospective payment system final rule published on August 1, 
2000 (65 FR 47090). In that final rule, we set forth the methodology 
for calculating the weighted average PRA and outlined the steps for 
determining whether a hospital's PRA would be revised.
2. Amendments Made by Section 511 of Public Law 106-554 
(Sec. 413.86(e)(4)(ii)(C) and (e)(5)(iv))
    Section 511 of Public Law 106-554 amended section 
1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of 
the locality-adjusted national average PRA. In general, section 511 
provides that, effective for cost reporting periods beginning on or 
after October 1, 2001, and before October 1, 2002, PRAs that are below 
85 percent of the respective locality-adjusted national average PRA 
would be increased to equal 85 percent of that locality-adjusted 
national average PRA. Accordingly, we proposed to implement section 511 
by revising Sec. 413.86(e)(4)(ii)(C)(1) to incorporate this change and 
by outlining the methodology for determining whether a hospital's 
PRA(s) will be adjusted in FY 2002 relative to the increased floor of 
the locality-adjusted national average PRA.
    In the August 1, 2000 final rule (65 FR 47091 and 47092), as 
implemented at Sec. 413.86(e)(4), we determined, in accordance with 
section 311 of Public Law 106-113, that the weighted average PRA for 
cost reporting periods ending during FY 1997 is $68,464. We described 
the procedures for updating the weighted average PRA of $68,464 for 
inflation to FY 2001 and for adjusting this average for the locality of 
each individual hospital. We then outlined the steps for comparing each 
hospital's PRA(s) to the locality-adjusted national average PRA to 
determine if, for cost reporting periods beginning on or after October 
1, 2000, and before October 1, 2001, the PRAs should be revised to 
equal the 70-percent floor.
    In accordance with section 511 of Public Law 106-554, in the May 4 
proposed rule, we proposed that, for cost reporting periods beginning 
during FY 2002, the FY 2002 PRAs of hospitals that are below 85 percent 
of the respective locality-adjusted national average PRA for FY 2002 be 
increased to equal 85 percent of that locality-adjusted national 
average PRA. Specifically, to determine which PRAs (primary care and 
nonprimary care separately) for each hospital are below the 85-percent 
floor, each hospital's locality-adjusted national average PRA for FY 
2002 is multiplied by 85 percent. This resulting number is then 
compared to each hospital's PRA that is updated for inflation to FY 
2002. If the hospital's PRA would be less than 85 percent of the 
locality-adjusted national average PRA, the individual PRA is replaced 
with 85 percent of the locality-adjusted national average PRA for that 
cost reporting period, and in future years the new PRA would be updated 
for inflation by the Consumer Price Index for All Urban Consumers (CPI-
U) as compiled by the Bureau of Labor Statistics.
    There may be some hospitals with both primary care and nonprimary 
care PRAs that are below the floor, and both PRAs are, therefore, 
replaced with 85 percent of the locality-adjusted national average PRA. 
In these situations, the hospitals would receive a single PRA; a 
distinction between PRAs would no longer be made based on the different 
inflation adjustments (under Sec. 413.86(e)(3)(ii)). On the other hand, 
hospitals may have primary care PRAs that are above the floor, and 
nonprimary care PRAs that are below the floor. In these situations, 
only the nonprimary care PRAs would be revised to equal 85 percent of 
the locality adjusted national average PRA, and the prior year primary 
care PRAs would be updated for inflation by the CPI-U. An example of 
application of this provision appeared in the preamble of the May 4, 
2001 proposed rule (66 FR 33697).
    We note that section 511 of Public Law 106-554 only affects 
hospitals with PRAs below the 85-percent floor, and does not affect 
hospitals with PRAs that are either between the floor and ceiling or 
exceed the ceiling. Thus, with the exception of the change in the floor 
as provided by section 511, the policy regarding the use of a national 
average PRA for making direct GME payments remains as implemented in 
the regulations at Sec. 413.86(e)(4).
    We proposed to amend Sec. 413.86(e)(4)(ii)(C)(1) to add the rules 
implementing section 1886(h)(2)(D)(iii) of the Act as amended by 
section 511 of Public Law 106-554.
    We also proposed to amend Sec. 413.86(e)(5) regarding the 
determination of base year PRAs for new teaching hospitals for cost 
reporting periods beginning during FYs 2001 through 2005. In the August 
1, 2000 final rule, we made a conforming change to Sec. 413.86(e)(5) to 
account for situations in which hospitals do not have a 1984 base year 
PRA and establish a PRA in a cost reporting period after the 1984 base 
year. Existing Sec. 413.86(e)(5)(iv) specifies that the new base year 
PRAs of such hospitals are subject to the regulations regarding the 
floor and the ceiling of the locality-adjusted national average PRA. 
Although the determination of new base year PRAs is subject to the 
national average methodology, it is not necessary to include this 
provision in the regulations. Therefore, we proposed to remove 
Sec. 413.86(e)(5)(iv).
    In the proposed rule, we clarified that, for purposes of 
calculating a base year PRA for a new teaching hospital, when 
calculating the weighted mean value of PRAs of hospitals located in the 
same geographic area or the weighted mean value of the PRAs in the 
hospital's census region (as defined in Sec. 412.62(f)(1)(i)), the PRAs 
used in the weighted average calculation must not be less than the 
floors for cost reporting periods beginning during FY 2001 or FY 2002, 
or if they exceed the ceiling, they must either be frozen for FYs 2001 
and 2002 or updated with the CPI-U minus 2 percent for FYs 2003 through 
2005. In addition, existing Sec. 413.86(e)(5) provides that the PRA for 
a new teaching hospital is based on the lower of the hospital's actual 
costs incurred in connection with the GME program or the weighted mean 
value of PRAs. If a hospital's actual costs of the GME program during 
its cost reporting period beginning during FY 2001 or FY 2002 are less 
than the floors, the hospital's PRA would not be based on the actual 
costs. Instead, it would be equal to 70 percent in FY 2001, or 85 
percent during FY 2002, of the locality-adjusted national average PRA. 
The floor applies to hospitals with existing PRAs in FYs 2001 and 2002, 
or to hospitals that are establishing new base year PRAs in FYs 2001 
and 2002. We proposed to clarify that if a hospital establishes a new 
base year PRA in a cost reporting period beginning after FY 2002, its 
PRA would not be increased to equal the floor if it is less than the 
floor. Similarly, the ceiling applies to hospitals with existing PRAS 
in FYs 2001 through 2005, or to hospitals that are establishing new 
base year PRAs in FYs 2001 through 2005.
    Comment: One commenter believed that the provision to increase the 
PRA floor to 85 percent of the locality-adjusted national average will 
address many concerns about the fairness of GME payments. One commenter 
asked if the provisions of the proposed rule to increase PRAs that are 
less than 85 percent of the locality-adjusted national average PRA to 
equal 85 percent of the locality-adjusted national average PRA would 
provide relief to hospitals who do not have base year PRAs established 
in the 1984 base year and could not increase their PRAs because the 
appeal period has elapsed.

[[Page 39893]]

    Response: Section 511 of the Public Law 106-554 amended section 
1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of 
the locality adjusted national average PRA. Effective for cost 
reporting periods beginning on or after October 1, 2001 and before 
October 1, 2002, any PRAs that are below 85 percent of the respective 
locality-adjusted national average PRA would be increased to equal 85 
percent of that locality-adjusted national average PRA. Accordingly, 
hospitals with PRAs (primary care and/or nonprimary care) that are less 
than 85 percent of the respective locality-adjusted national average 
PRA for the hospital's cost reporting period beginning on or after 
October 1, 2001 and before October 1, 2002, will have those PRAs 
increased to equal 85 percent of that locality-adjusted national 
average PRA. This provision sets the floor on per resident amounts for 
cost reporting periods beginning during FY 2002, regardless of the base 
year used to establish the hospital's PRA.
    Comment: One commenter requested that we clarify the references in 
the preamble stating that the national average PRA methodology is 
applicable for ``cost reporting periods beginning on or after October 
1, 2000 and on or before September 30, 2005.'' The commenter believed 
that the PRA changes authorized in the law were meant to be permanent, 
and therefore, did not understand the basis for the September 30, 2005 
endpoint.
    Response: The changes made to a hospital's PRA as a result of 
section 311 of Public Law 106-113 and section 511 of Public Law 106-554 
are permanent. However, this new methodology for determining whether or 
not a hospital's PRA is revised, as described in the statute, is only 
effective for cost reporting periods beginning on or after October 1, 
2000 and on or before September 30, 2005. For cost reporting periods 
beginning on or after October 1, 2005, a hospital's PRA, whether or not 
it was revised by the new methodology, is updated with the full CPI-U, 
using the procedures in place prior to October 1, 2000. If a hospital's 
PRAs are below the floors, they will be revised accordingly in FYs 2001 
or 2002, or both. After FY 2002, that hospital's revised PRA will be 
updated for inflation as usual, that is, using the procedures in place 
for all PRAs prior to October 1, 2000. If a hospital's PRAs exceed the 
ceiling, the PRAs would be frozen in FYs 2001 and 2002, and updated 
with a reduced inflation factor in FYs 2003, 2004, and 2005. Thus, 
after September 30, 2005, although any changes made to a hospital's 
PRAs as a result of the new methodology would remain in place, the 
procedure for updating PRAs reverts back to the procedure in place 
prior to October 1, 2000, that is, updating for inflation with the full 
CPI-U.
    Comment: One commenter requested that we publish in the final rule 
the CPI-U factors that must be used to update the 1997 national average 
PRA to the midpoint of a hospital's cost reporting period beginning in 
FY 2001.
    Response: As the commenter requested, we are including below the 
CPI-U factors. For cost reporting periods beginning on or after October 
1, 2000 and before October 1, 2001, the following update factors should 
be used when implementing section 311 of Public Law 106-113. Specific 
instructions for applying these factors can be found in the hospital 
inpatient prospective payment system final rule published on August 1, 
2000 (65 FR 47091). (Refer to the bottom of the middle column and the 
right column on page 47091 for ``Step 1: Update the weighted average 
PRA for inflation''.)

  GME Update Factors for Midpoint of Periods Ending in FY 1997 to Cost
   Reporting Periods Beginning in FY 2001 Using the CPI (U)--All Items
------------------------------------------------------------------------
                                   To midpoint of cost
  Update weighted average PRA        reporting period       Use update
             from:                      beginning:        factor of: \*\
------------------------------------------------------------------------
October 1, 1996................  October 1, 2000........         1.11200
October 1, 1996................  November 1, 2000.......         1.11389
October 1, 1996................  December 1, 2000.......         1.11579
October 1, 1996................  January 1, 2001........         1.11800
October 1, 1996................  February 1, 2001.......         1.12053
October 1, 1996................  March 1, 2001..........         1.12307
October 1, 1996................  April 1, 2001..........         1.12465
October 1, 1996................  May 1, 2001............         1.12528
October 1, 1996................  June 1, 2001...........         1.12591
October 1, 1996................  July 1, 2001...........         1.12780
October 1, 1996................  August 1, 2001.........         1.13097
October 1, 1996................  September 1, 2001......         1.13414
------------------------------------------------------------------------
\*\ Source: Forecast by Standard and Poor's DRI; Historical Data through
  August 2000.

3. Determining the 3-Year Rolling Average for Direct GME Payments 
(Sec. 413.86(g)(4) and (g)(5))
    Section 1886(h)(4)(G)(iii) of the Act, as added by section 4623 of 
Public Law 106-33, provides that for the hospital's first cost 
reporting period beginning on or after October 1, 1997, the hospital's 
weighted FTE count for direct GME payment purposes equals the average 
of the weighted FTE count for that cost reporting period and the 
preceding cost reporting period. For cost reporting periods beginning 
on or after October 1, 1998, section 1886(h)(4)(G) of the Act requires 
that hospitals' direct medical education weighted FTE count for payment 
purposes equal the average of the actual weighted FTE count for the 
payment year cost reporting period and the preceding two cost reporting 
periods (rolling average). This provision phases in the associated 
reduction in payment over a 3-year period for hospitals that are 
reducing their number of residents.
    In the August 29, 1997 final rule with comment period (62 FR 
46004), we revised Sec. 413.86(g)(5) accordingly, and outlined the 
methodology for determining a hospital's direct GME payment. Based on 
what we explained in the 1997 final rule, for cost reporting periods 
beginning on or after October 1, 1997, we would determine a hospital's 
direct GME payment as follows:
    Step 1. Determine the average of the weighted FTE counts for the 
payment year cost reporting period and the prior two immediately 
preceding cost reporting periods (with exception of the hospital's 
first cost reporting period beginning on or after October 1, 1997, 
which will be based on the average of the weighted average for that 
cost

[[Page 39894]]

reporting period and the immediately preceding cost reporting period).
    Step 2. Determine the hospital's direct GME amount without regard 
to the FTE cap (before determining Medicare's share). That is, take the 
sum of (a) the product of the primary care PRA and the primary care 
weighted FTE count in the current payment year, and (b) the product of 
the nonprimary care PRA and the nonprimary care weighted FTE count in 
the current payment year.
    Step 3. Divide the hospital's direct GME amount by the total number 
of FTE residents (including the effect of weighting factors) for the 
cost reporting period to determine the weighted average PRA (this 
amount reflects the FTE weighted average of the primary and nonprimary 
care PRAs) for the cost reporting period.
    Step 4. Multiply the weighted average PRA for the cost reporting 
period by the 3-year average weighted count to determine the hospital's 
allowable direct GME costs. This product is then multiplied by the 
hospital's Medicare patient load for the cost reporting period to 
determine Medicare's direct GME payment to the hospital.
    Steps 2 and 3 above describe the methodology for combining a 
hospital's primary care PRA and nonprimary care PRA to determine the 
hospital's single weighted average PRA for the payment year cost 
reporting period. (This step accounts for hospitals that were training 
residents in both primary care and nonprimary care residency programs 
in FYs 1994 and 1995, when, as described in Sec. 413.86(e)(3)(ii), each 
hospital's PRA for the previous cost reporting period was not adjusted 
for any resident FTEs who were not either a primary care resident or an 
obstetrics and a gynecology resident. As a result, such hospitals have 
two PRAs for direct GME payment; one for primary care and obstetrics 
and gynecology residents, and one for all other, or nonprimary care, 
residents. Hospitals that train either only primary care (including 
obstetrics and gynecology) residents or only nonprimary care residents 
follow the methodology described above, with the exception of combining 
two PRAs. Step 4 then dictates that the resulting average PRA is 
multiplied by the 3-year rolling average, which, in turn, is multiplied 
by the hospital's Medicare patient load in the current year to 
determine Medicare's direct GME payment to the hospital for that cost 
reporting period.
    In implementing this provision in the August 29, 1997 final rule 
with comment period, we believed that the methodology described above 
was appropriate because it was consistent with the methodology 
described under section 1886(h)(3)(B) of the Act. This section 
specifies that, in order to arrive at the average PRA, or ``aggregate 
approved amount,'' the Secretary must multiply a hospital's PRA by the 
``weighted average number of [FTE] residents * * * in the hospital's 
approved medical residency training programs in that period'' (emphasis 
added).
    We also believed the methodology outlined above and in the August 
29, 1997 rule was appropriate because it was consistent with the intent 
of the statute that, after October 1, 1997, direct GME payments should 
be based on a rolling average. Specifically, section 4623 of Public Law 
106-33 provides that, ``For cost reporting periods beginning on or 
after October 1, 1997 * * * the total number of full-time equivalent 
residents for determining a hospital's graduate medical education 
payment shall equal the average of the actual full-time equivalent 
resident counts for the cost reporting period and the preceding two 
cost reporting periods' (emphasis added). Thus, while the statute does 
not include a specific methodology for computing the direct GME 
payments, it clearly indicates that the payment should be based on a 3-
year average of the weighted number of residents, not the weighted 
number of residents in the current payment year cost reporting period.
    As stated above, Congress provided that the direct GME payments 
should be made based on a 3-year average of the weighted number of 
residents in order to phase in the associated reduction in payment over 
a 3-year period for hospitals that are reducing the number of residents 
they are training. However, in steps 2 and 3 above, when combining a 
hospital's primary care PRA and nonprimary care PRA, we weight the 
respective PRAs by current year residents. This introduces the number 
of residents that a hospital is training in the current cost reporting 
period into the payment formula. A payment formula that incorporates 
the number of current year residents ``dilutes'' the effect of the 
rolling average as related to direct GME payments. After further 
consideration, we believe that, consistent with the statute, the 
formula should be based on rolling average counts of residents. We 
proposed an alternative methodology which would replace the current 
methodology in which the direct GME payment would be the sum of (a) the 
product of the primary care PRA and the primary care and obstetrics and 
gynecology rolling average, and (b) the product of the nonprimary care 
PRA and the nonprimary care rolling average. (This sum would then be 
multiplied by the Medicare patient load.) The new methodology would 
only be used for determining direct GME payments because there is no 
distinction between primary care and nonprimary care residents for IME 
payment purposes.
    The new methodology is effective for cost reporting periods 
beginning on or after October 1, 2001. The methodology for determining 
a hospital's direct GME payment is as follows:
    Step 1. Determine that the hospital's total unweighted FTE counts 
in the payment year cost reporting period and the prior two immediately 
preceding cost reporting periods for all residents in allopathic and 
osteopathic medicine do not exceed the hospital's FTE cap for these 
residents in accordance with Sec. 413.86(g)(4). If the hospital's total 
unweighted FTE count in a cost reporting period exceeds its cap, the 
hospital's weighted FTE count, for primary care and obstetrics and 
gynecology residents and nonprimary care residents, respectively, will 
be reduced in the same proportion that the number of these FTE 
residents for that cost reporting period exceeds the unweighted FTE 
count in the cap. The proportional reduction is calculated for primary 
care and obstetrics and gynecology residents and nonprimary care 
residents separately in the following manner:

(FTE cap/unweighted total FTEs in the cost reporting period)  x  
(weighted primary care and obstetrics and gynecology FTEs in the 
cost reporting period)

        plus

(FTE cap/unweighted total FTEs in the cost reporting period)  x  
(weighted nonprimary care FTEs in the cost reporting period).

    Add the two products to determine the hospital's reduced cap.
    Step 2. Determine the 3-year average of the weighted FTE count for 
primary care and obstetrics and gynecology residents in the payment 
year cost reporting period and the two immediately preceding cost 
reporting periods. Determine the 3-year average of the weighted FTE 
count for nonprimary care residents in the payment year cost reporting 
period and the two immediately preceding cost reporting periods.
    Step 3. Determine the product of the primary care PRA and the 
primary care and obstetrics and gynecology 3-year average from step 2. 
Determine the product of the nonprimary care PRA and the nonprimary 
care 3-year average from step 2.
    Step 4. Sum the products of step 3.
    Step 5. Multiply the sum from step 4 by the hospital's Medicare 
patient load

[[Page 39895]]

for the cost reporting period to determine Medicare's direct GME 
payment to the hospital.
    Existing Sec. 413.86(g)(5) specifies that residents in new programs 
are excluded from the rolling average calculation for a period of years 
equal to the minimum accredited length for the type of program, and are 
added to the payment formula after applying the averaging rules. 
Accordingly, for hospitals that qualify for an adjustment to their FTE 
caps for residents training in new programs under Sec. 413.86(g)(6), 
primary care and obstetrics and gynecology residents in new programs 
would be added to the quotient of the primary care and obstetrics and 
gynecology 3-year average, and nonprimary care residents in new 
programs would be added to the quotient of the nonprimary care 3-year 
average. The sums of the respective 3-year averages and new residents 
would then be multiplied by the respective PRAs.
    The following example illustrates the determination of direct GME 
payment under the proposed rolling average methodology for an existing 
teaching hospital with no new programs:

    Example: Assume a hospital with a cost reporting period ending 
September 30, 1996 (beginning October 1, 1995) had 100 unweighted 
FTE residents and 90 weighted FTE residents. The hospital's FTE cap 
is 100 unweighted residents.

    Step 1. In its cost reporting period beginning in FY 2000, it had 
100 unweighted residents and 90 weighted residents (50 primary care and 
40 nonprimary care).
     The hospital had 90 unweighted residents and 85 weighted 
residents (50 primary care and 35 nonprimary care) for its cost 
reporting period beginning in FY 2001.
     In its cost reporting period beginning in FY 2002, the 
hospital had 80 unweighted residents and 80 weighted residents (50 
primary care and 30 nonprimary care).
    Step 2. The 3-year average of weighted primary care and obstetrics 
and gynecology residents is (50 +50 + 50)/3 = 50. The 3-year average of 
weighted nonprimary care residents is (40 + 35 + 30)/3 = 35.
    Step 3. Primary care: $80,000 PRA  x  50 weighted primary care and 
obstetrics and gynecology FTEs = $4,000,000. Nonprimary care: $78,000 
x  35 weighted nonprimary care FTEs = $2,730,000.
    Step 4. $4,000,000 + $2,730,000 = $6,730,000.
    Step 5. If the hospital's Medicare patient load for the payment 
cost reporting period is .20, Medicare's direct GME payment would be 
$6,730,000  x  .20 = $1,346,000.
    Whether the proposed methodology results in a payment difference 
for a hospital is dependent upon whether or not the number and mix 
(primary care and nonprimary care) of FTEs changes in a 3-year period. 
If the number and mix of FTEs does not change in a 3-year period, there 
would be no difference in a direct GME payment amount derived using the 
proposed methodology versus the existing methodology. For example, if a 
hospital has 90 weighted FTEs (50 primary care and 40 nonprimary care) 
in the current year and the 2 previous years (using the PRAs and the 
Medicare patient load from the example above), the payment amounts 
derived from the existing methodology and the proposed methodology 
would be equal.
    If the number and mix of FTEs varies from year to year, there will 
be a difference in the results of the two methodologies. In some 
instances the existing methodology would result in a higher payment, 
and in other instances the proposed methodology would result in a 
higher payment. In the example above, the hospital has reduced its 
number of weighted residents by 5 FTEs in FYs 2001 and 2002. 
Calculating this hospital's direct GME payment amount using the 
existing methodology (using the PRAs and the Medicare patient load from 
the example) would result in a payment of $1,347,250, which is $1,250 
more than $1,346,000, the amount calculated in the example using the 
proposed methodology.
    In a scenario where a hospital makes larger reductions to the 
number of FTEs, the proposed methodology may be more beneficial. For 
example, using the PRAs and the Medicare patient load from the example 
above, assume a hospital has 90 weighted FTEs (50 primary care and 40 
nonprimary care) in FY 2000, 85 weighted FTEs (50 primary care and 35 
nonprimary care) in FY 2001, and 70 weighted FTEs (35 primary care and 
35 nonprimary care) in FY 2002. If the proposed methodology is used, 
the payment amount of $1,292,050 would be calculated, which is $1,666 
more than $1,290,386, the amount calculated if the existing methodology 
is used.
    We proposed to revise Sec. 413.86(g)(4) to specify that, effective 
for cost reporting periods beginning on or after October 1, 2001, if 
the hospital's total unweighted FTE count in a cost reporting period 
exceeds its cap, the hospital's weighted FTE count, for primary care 
and obstetrics and gynecology residents and nonprimary care residents, 
respectively, will be reduced in the same proportion that the number of 
these FTE residents for that cost reporting period exceeds the 
unweighted FTE count in the cap. We also proposed to revise 
Sec. 413.86(g)(5) to specify that, effective for cost reporting periods 
beginning on or after October 1, 2001, the direct GME payment will be 
calculated using two separate rolling averages, one for primary care 
and obstetrics and gynecology residents and one for nonprimary care 
residents.
    Comment: Two commenters asked whether or not the proposed new 
methodology for calculating direct GME payment using two separate 
rolling averages for primary care and nonprimary care residents is 
truly an ``alternative,'' or, if finalized, would it replace the 
present methodology.
    Response: The proposed new methodology would replace the existing 
rolling average methodology effective for cost reporting periods 
beginning on or after October 1, 2001 (the effective date of this final 
rule). Hospitals training both primary care and nonprimary care 
residents would determine two separate rolling average counts; one for 
primary care and one for nonprimary residents.
    Comment: One commenter stated: ``although the new rolling average 
methodology is difficult and complex, its impact on GME programs is far 
from clear.'' The commenter asked how much change in resident number 
and mix is necessary before this new methodology has an effect on 
payment, and stated that more examples would be helpful in determining 
this effect. The commenter also expressed hope that, if this change is 
finalized, we will revisit this issue after implementation and fully 
examine and analyze its impact on teaching program payment.
    Response: As we explained in the proposed rule, whether the new 
methodology results in a payment difference for a hospital is dependent 
upon whether or not the ratio of primary care to nonprimary care FTEs 
changes in a 3-year period. If the ratio of the FTEs does not change 
over the 3-year period, there would be no difference in a direct GME 
payment amount derived using the new methodology versus the existing 
methodology. In particular, there would be an increase in direct GME 
payment under the revised methodology, where a hospital's proportion of 
primary care residents to nonprimary care residents over the last 3 
years is higher than the hospital's proportion of primary care 
residents to nonprimary care residents in the current year. As this new 
rolling average methodology is implemented, we intend to evaluate 
hospitals' direct GME payments to further analyze the impact of using 
this methodology.
    Comment: One commenter asked how many hospitals would still be ``at 
risk''

[[Page 39896]]

for changes in payment because they retain different primary care and 
nonprimary care PRAs, given the implementation of the 85 percent floor.
    Response: As described in the impact section of this final rule in 
Appendix A, we estimated that, of 1,231 teaching hospitals included in 
the analysis, approximately 562 hospitals have PRAs that will be 
increased to equal 85 percent of the national average PRA. This leaves 
669 hospitals with PRAs that exceed the 85 percent floor. However, not 
all of these hospitals will be using the new methodology because not 
all of them have both primary care and nonprimary care PRAs.
    Comment: One commenter noted that, in order to implement the new 
rolling average methodology, significant changes must be made to 
Worksheet E, Part A, the worksheet on the Medicare cost report used for 
calculating a hospital's IME adjustment. The commenter also stated that 
past cost reports using the current cost reporting forms would have to 
be reopened.
    Response: As we explained in the preamble to the proposed rule and 
above in this final rule, we have decided to institute a separate 
rolling average for primary care and nonprimary care residents due to 
an issue with respect to the current payment methodology for direct GME 
only. That is, when combining a hospital's primary care PRA and 
nonprimary care PRA on Worksheet E-3, Part IV of the Medicare cost 
report, we currently weight the respective PRAs by current year 
residents. As a result, although Congress provided that the direct GME 
payments should be made based on a 3-year rolling average count of 
weighted residents, the current methodology introduces the number of 
residents that a hospital is training in the current cost reporting 
period into the payment formula. A payment formula that incorporates 
the number of current year residents ``dilutes'' the effect of the 
rolling average as related to direct GME payments. However, in regard 
to the IME payments, we also noted that, although they are also based 
on a rolling average, no change in the existing methodology is needed 
because there is no distinction between primary care and nonprimary 
care residents for IME payment purposes. Therefore, while two separate 
rolling averages will be used for direct GME payments (one for primary 
care and one for nonprimary care), a single rolling average will 
continue to be used for IME payments under the existing methodology. We 
will make the necessary changes to the Medicare cost report on 
Worksheet E-3, Part IV, which is used for calculating a hospital's 
direct GME payment, to accommodate two separate rolling average 
calculations.
    The commenter also stated that affected cost reports in which the 
current rolling average methodology was used would need to be reopened. 
However, the effective date of this change in the methodology is 
prospective, and will only affect cost reporting periods beginning on 
or after October 1, 2001. We will not be reopening past cost reports to 
change direct GME payment because of the new methodology.
    Comment: One commenter indicated that the separation of the 3-year 
rolling average between primary care and nonprimary care FTEs will be 
difficult because the prior year FTEs were not separated into primary 
care and nonprimary care FTEs. The commenter asked how a provider could 
obtain the information from prior years if the same methodology was not 
used.
    Response: We do not believe it will be difficult for a hospital to 
obtain the weighted FTE counts of its primary care and nonprimary care 
residents separately. This is because, in fact, although the rolling 
average was computed based on total residents, there are lines on 
Worksheet E-3, Part IV (lines 3.07 and 3.08) in which the current year 
weighted count of primary care and nonprimary care residents are 
reported separately. Therefore, the hospital and the fiscal 
intermediary can easily refer to these lines on prior year cost reports 
to determine a 3-year average for primary care and nonprimary care 
residents, respectively.
4. Counting Research Time as Direct and Indirect GME Costs 
(Secs. 412.105 and 413.86)
    It has come to our attention that there appears to be some 
confusion in the provider community as to whether the time that 
residents spend performing research is countable for the purposes of 
direct and indirect GME reimbursement. Although we did not propose to 
make any policy changes in the May 4 proposed rule, we did reiterate 
our longstanding policy regarding time that residents spend in research 
and proposed to incorporate this policy in the IME regulations.
    Section 413.86(f) specifies that, for the purposes of determining 
the total number of FTE residents for the direct GME payment, residents 
in an approved program working in all areas of the hospital complex may 
be counted. Accordingly, the time the residents spend performing 
research as part of an approved program anywhere in the hospital 
complex may be counted for direct GME payment purposes. If the 
requirements listed at Secs. 413.86(f)(3) and (f)(4) are met, a 
hospital may also count the time residents spend doing research in 
nonhospital settings for direct GME payment.
    For purposes of determining the IME payment, Sec. 412.105(f)(1)(ii) 
specifies that the time residents spend training in parts of the 
hospital that are subject to the inpatient prospective payment system, 
in the outpatient departments, or (effective on or after October 1, 
1997, in accordance with Sec. 413.86(f)(3) or (f)(4), as applicable) in 
nonhospital settings, may be counted. Section 2405.3.F.2. of the 
Provider Reimbursement Manual (PRM) further states that a resident must 
not be counted for the IME adjustment if the resident is engaged 
exclusively in research. Resident time spent ``exclusively'' in 
research means that the research is not associated with the treatment 
or diagnosis of a particular patient of the hospital. Therefore, 
although the research component may be part of an approved program, the 
time that residents devote specifically to performing research that is 
not related to delivering patient care, whether it occurs in the 
hospital complex or in non-hospital settings, may not be counted for 
IME payment purposes. ``Exclusively research'' time is not allowable 
for IME purposes irrespective of whether the resident is engaged only 
in research or spends only part of his or her time on research. 
Accordingly, time spent exclusively in research over the course of a 
program year should be subtracted from the total FTE count for that 
year. For example, if a resident is required to spend 3 months in a 
particular program year engaged in research activities unrelated to 
delivering patient care, that amount of time should be subtracted from 
the total FTE count, whether or not the research time is fulfilled in 
one block of time, or is distributed throughout the training year.
    We note that in order to count residents for both direct GME and 
IME payment purposes, the residents' training must be part of an 
approved program. This applies whether or not the residents are doing 
work that is clinical in nature. There are situations where residents 
have completed their residency program requirements but remain for an 
additional period of time to continue their training (that is, to 
conduct research or other activities) outside the context of a formally 
organized approved program. As we explained in the September 29, 1989 
final rule (54 FR 40306), these residents are not countable for direct 
GME or IME

[[Page 39897]]

reimbursement. Rather, patient care services provided by these 
residents should be paid as Part B services.
    We proposed to amend Sec. 412.105(f)(1)(iii) to add a paragraph (B) 
to incorporate language that reflects this policy.
    We received several comments disagreeing with our clarification to 
longstanding policy on whether the time that residents spend performing 
research may be included in the FTE count for the purpose of 
determining direct and indirect GME reimbursement.
    Comment: One commenter stated that the proposed revised IME 
regulations at Sec. 412.105 do not mention any requirement that 
residents counted for purposes of the IME adjustment and assigned to a 
hospital's inpatient prospective payment system or outpatient area be 
involved in ``patient care activities.'' Instead, that requirement is 
only mentioned with reference to residents assigned to nonprovider 
settings. Therefore, the commenter believed that a patient care 
requirement in reference to counting residents in nonprovider settings 
implies the exclusion of the same requirement when counting residents 
in the hospital (specifically as it applies to counting research time 
for IME purposes).
    Response: The clarification in the proposed rule addresses our 
longstanding interpretation of existing regulations and reflects 
longstanding general Medicare reimbursement principles. Under general 
Medicare reimbursement principles, as reflected in Sec. 413.9, costs 
incurred by a hospital generally must be related to patient care in 
order to be reimbursed by Medicare.
    The purpose of the IME payments is to address the additional costs 
that hospitals incur in treating patients. In our May 6, 1986 interim 
final rule (51 FR 16775), we stated: ``Section 1886(d)(5)(B) of the Act 
provides that prospective payment hospitals receive an additional 
payment for the indirect costs of medical education computed in the 
same manner as the adjustments for those costs under regulations in 
effect as of January 1, 1983. Under those regulations, we provided that 
the indirect costs of medical education incurred by teaching hospitals 
are the increased operating costs (that is, patient care costs) that 
are associated with approved intern and resident programs'' (emphasis 
added). In addition, in our September 29, 1989 final rule (54 FR 
40286), we specifically state: ``As used in section 1886(d)(5)(B) of 
the Act, `indirect medical education' means those additional costs 
(that is, patient care costs) incurred by hospitals with graduate 
medical education programs. The indirect costs of medical education 
might, for example, include added costs resulting from an increased 
number of tests ordered by residents as compared to the number of tests 
normally ordered by more experienced physicians'' (emphasis added).
    Thus, payments for IME address the additional operating costs that 
teaching hospitals incur in furnishing patient care. Accordingly, 
consistent with the purpose of IME payments and general Medicare 
reimbursement principles, in determining the FTE count with respect to 
the IME adjustment, it has been our longstanding policy that we do not 
include residents to the extent that the residents are not involved in 
furnishing patient care but are instead engaged exclusively in 
research.
    Comment: One commenter disagreed with our use of the Provider 
Reimbursement Manual (PRM), section 2405.3.F.2, in support of our 
policy on excluding residents from the IME count if the resident is 
``engaged exclusively in research.'' The commenter stated that the 
reference to exclusion from the resident count for residents engaged 
``exclusively in research'' must be read in the context of the Manual 
provision, and not in a regulatory vacuum. The commenter believed that 
PRM section 2405.3.F.2 is addressing situations outside of the 
traditional residency program--where the resident time at issue is not 
part of an approved medical education program. The commenter believed 
that the phrase ``engaged exclusively in research'' refers to persons 
who are research scientists and not engaged in research as part of a 
clinical residency program.
    In addition, this commenter stated that our interpretation of the 
word ``exclusively'' in this context is not reasonable and is contrary 
to the clear meaning of the term. The commenter argued that our 
interpretation practically eliminates the word ``exclusively,'' 
effectively saying that a resident is ``exclusively engaged in 
research'' if that resident participates in any research at all.
    Response: Section 2405.3.F.2 of the PRM (published in August 1988) 
was written to address ``Questionable situations'' for the IME FTE 
count. Indeed, in the introductory paragraph in this section we state: 
``It is recognized that situations arise in which it may be unclear 
whether an individual is counted as an intern or resident in an 
approved program for the purposes of the indirect medical education 
adjustment.'' Thus, the point of section 2405.3.F.2 of the PRM was to 
clarify situations for counting resident FTEs in approved programs for 
IME purposes. As the commenter suggested, some of the situations listed 
under this section address situations where the resident FTE time at 
issue is not part of the approved medical education program (for 
example, that a resident must not be counted for the IME adjustment if 
``the individual's services in provider settings are payable as 
physician services (situations in which it is clear that the otherwise 
eligible resident is `moonlighting')''.) (Section 2405.3.F.2. of the 
PRM). However, this section in the PRM was written to clarify counting 
rules for IME purposes in various situations. In addition to clarifying 
situations where resident time is spent in an unapproved program, this 
section in the PRM certainly also clarifies the rules for determining 
resident time spent in an approved program--such as time the resident 
is ``engaged exclusively in research'' (as cited in the proposed rule) 
and that ``any portion of the individual's salary is subject to 
reasonable compensation equivalency limits.'' (Section 2405.3.F.2. of 
the PRM)
    Therefore, we do not agree with the commenter that we have read 
this manual provision in a ``regulatory vacuum''. The phrase ``engaged 
exclusively in research'' is not meant only to refer to persons who are 
research scientists and not engaged in research as part of an approved 
clinical residency program, since as explained above, there is nothing 
in the manual provision that limits the research provision to research 
performed outside of an approved program.
    In the proposed rule, we stated that resident time spent 
``exclusively'' in research ``means that the research is not associated 
with the treatment or diagnosis of a particular patient of the 
hospital.'' (66 FR 22700). The commenter argued that this 
interpretation of the word ``exclusively'' in the context of the manual 
provision is unreasonable and contrary to the clear meaning of the 
term, that under our policy, a resident would be ``engaged exclusively 
in research'' if that resident participates in any research at all. We 
do not agree.
    Resident time spent ``engaged exclusively in research'' means time 
not associated with the care of a particular patient (see proposed 
Sec. 412.105(f)(1)(iii)(B)); thus, any research time that is associated 
with the treatment or diagnosis of a particular hospital patient or, 
effective on or after October 1, 1997, of patients in nonhospital 
settings, that is, usual patient care, is countable for IME payment 
purposes. We note that this distinction between activities that are

[[Page 39898]]

``usual patient care'' and research activities is, again, longstanding 
Medicare policy. In April 1975, at section 500 of the PRM, we stated 
the principle that ``Costs incurred for research purposes, over and 
above usual patient care, are not included as allowable costs.'' 
Indeed, since the inception of Medicare, we have distinguished between 
activities that are ``usual patient care'' and activities that are 
outside this scope, such as research activities.
    Comment: One commenter stated that ``by its very nature as a 
regression analysis, or statistical measure, the IME formula is not 
intended to be dependent on `the treatment or diagnosis of a particular 
patient of the hospital.' '' Another commenter stated: ``our 
understanding of the development of the adjustment is that statistical 
analyses showed that the use of an intern/resident-to-bed ratio (IRB) 
was (and continues to be) the best proxy for the patient care cost 
differences between teaching and non-teaching hospitals. Given that the 
IRB is only a proxy, the relevance of a requirement that residents 
themselves must be engaged in activities related to patient care in 
order for their training time to be counted in the IRB is unclear.''
    Response: Generally, the statistical analyses used in the 
development of the statutory IME adjustment measured the differences 
between teaching and nonteaching hospitals with respect to the 
additional costs associated with patient care. Inpatient hospital care 
that involves the use of residents is costlier than inpatient hospital 
care that does not involve the use of residents. As the comments and 
the statute reflect, the hospital's ratio of interns and residents to 
beds is one factor in measuring the additional costs that a hospital 
incurs due to the use of residents in furnishing patient care. While a 
resident is engaged exclusively in research, the hospital is not 
incurring additional patient care costs due to that resident. 
Accordingly, we believe that the measure of additional patient care 
costs is more accurate if it excludes residents engaged exclusively in 
research.
    Suppose, for example, that a teaching hospital has a total of 20 
FTE residents training in prospective payment system sections of the 
hospital who are all involved in furnishing patient care. The amount of 
the IME payment to the hospital would reflect 20 FTE residents, 
reflecting the additional operating costs arising from the use of 20 
FTE residents in furnishing patient care. Now suppose that the same 
hospital has the same 20 residents involved in furnishing patient care 
but it also has 4 additional FTE residents engaged exclusively in 
research. The 4 residents engaged exclusively in research do not 
contribute to higher operating costs and, therefore, as our 
longstanding policy reflects, we believe it is appropriate not to count 
them for purposes of the IME adjustment. Thus, in both situations, the 
hospital's FTE count for purposes of IME is 20. If we did make higher 
payments in the second situation, then the hospital would receive 
higher payments even though the hospital did not incur higher patient 
care costs.
    Comment: One commenter stated that our regulations at 
Sec. 413.86(e)(1)(i)(B) clearly allow research time to be counted for 
direct GME purposes. This commenter asserted that ``it cannot be 
reasonably argued that research time should be counted differently for 
IME than direct GME based on a new, very specific definition of patient 
care that applies solely to IME''. Another commenter stated the 
proposed rule is ``unduly burdensome'' by requiring hospitals to 
maintain different counts for direct GME and IME based on research 
activity or rotations. A third commenter stated that there is an 
alternative to distinguishing between direct GME and IME as it relates 
to research--``lawyers, often when faced with conflicting sections of 
the law, attempt to reconcile a common policy out of these conflicts, 
rather than further complicating things. You could do the same here.''
    Response: As we have stated above and in the proposed rule, the 
clarification we made concerning the counting of FTEs for research time 
related to the diagnosis and treatment of a particular patient for IME 
purposes is longstanding Medicare reimbursement policy. We were not 
proposing a change in Medicare policy.
    We are not introducing unnecessary complexity to the direct and 
indirect medical education counts, since it has always been Medicare 
policy to require the hospital to distinguish between time spent by 
residents involved exclusively in research and time spent on patient 
care. Further, the IME and direct GME FTE counts have and will continue 
to differ for several reasons. Hospitals have always been able to count 
residents in all areas of the hospital complex for direct GME but 
cannot count residents working in units exempt from the prospective 
payment system for IME. In addition, each resident included in the 
hospital's direct GME FTE count is counted as 0.5 FTE if they have 
trained beyond the number of years required to become eligible in the 
specialty in which they first began training. These same residents are 
counted as 1.0 FTE in the hospital's IME FTE count. We reiterate that 
we are not making a change in policy, but merely clarifying our policy 
with respect to counting residents involved in GME.
    With respect to research, our policies for direct GME payment are 
consistent with our policies for IME payment. In both contexts, we do 
not pay for the costs of time spent by residents engaged exclusively in 
research. In making payments for IME and direct GME for a given year, 
it is true that we treat research time differently for purposes of the 
IME FTE count and the direct GME FTE count, but, as explained below, 
this difference arises from the direct GME base year methodology and 
does not mean that we pay for research costs in the direct GME payment.
    In the September 29, 1989 final rule implementing the direct GME 
base year payment methodology, we described the calculation of the per 
resident amounts (PRAs). Each hospital's PRA is determined by taking 
the hospital's total allowable graduate medical education costs (which 
do not include costs allocated to the nursery cost center, research, 
and other nonreimbursable cost centers) in a base year and dividing the 
costs by the number of FTE residents working in all areas of the 
hospital complex in the base year. (Sec. 413.86(e)(1)(i)) In the case 
of research and other nonreimbursable cost centers, costs were excluded 
from the PRA calculation because they were nonreimbursable in the base 
year, consistent with longstanding Medicare policy on Medicare cost 
reimbursement to teaching hospitals. Ideally, residents engaged 
exclusively in research would also have been excluded from the base 
year FTE count used in the PRA calculation. However, for a number of 
hospitals, the FTE count for the base year did include residents 
engaged exclusively in research because the 1984 base year information 
available when the PRAs were determined in 1990 did not distinguish 
between residents involved in furnishing patient care services and 
residents exclusively engaged in research.
    In order to avoid disadvantaging these hospitals, in making direct 
GME payments for a given year, we have included and continue to include 
residents exclusively engaged in research in the direct GME FTE count 
both in the base year PRA calculation and in the FTE count in 
subsequent payment year calculations. Doing so ``offsets'' the effects 
of the inclusion of such residents in the direct GME base year FTE 
count (no such ``offset'' is necessary in the context of IME). However, 
because the costs were

[[Page 39899]]

excluded in calculating the PRA, the end result is that the direct GME 
payment does not encompass the costs of residents engaged exclusively 
in research. Therefore, as with the IME payment, Medicare is not and 
has not been reimbursing teaching hospitals under direct GME for costs 
the hospital incurs associated with resident time spent in research 
unrelated to usual patient care.
    Comment: One commenter stated that our policy on counting research 
time is well stated and clear. However, this commenter stated that 
there is much research that is done outside any funding source, but is 
an essential part of the resident's training. The commenter further 
stated that the hospital does assume these costs, and they are not part 
of the direct GME component, and so represent valid hospital 
expenditures due to the presence of residents.
    Response: We certainly acknowledge that hospitals incur research 
costs associated with the training of interns and residents. We 
understand that many specialties require a research component to be 
completed as part of the specialties' board eligibility requirements. 
The question as far as IME payments are concerned is whether or not the 
research is associated with the diagnosis and treatment of a particular 
patient. As explained above, teaching hospitals receive Medicare IME 
payments to pay hospitals for Medicare's share of the additional costs 
these hospitals incur associated with patient care costs; if the 
research is not associated with usual patient care costs, then the 
resident research time is not reimbursable.
    Comment: Two commenters stated that they are concerned that 
clarifications on the exclusion of resident FTEs from the IME payment 
for trainees engaged in activities that are purely research would be 
extended to include those individuals in an approved program that 
requires research activities at the same time as the delivery of 
patient care.
    Response: As stated above, where the residents are engaged 
exclusively in research, it is appropriate to exclude that time from 
the IME payment calculation. However, consistent with longstanding 
policy, in the situation where residents are in an approved program 
participating in research activities that are associated with the 
diagnosis and treatment of a particular patient, we believe it is 
appropriate to include that time in the IME payment calculation.
5. Temporary Adjustments to FTE Cap to Reflect Residents Affected by 
Residency Program Closure
    In the July 30, 1999 hospital inpatient prospective payment system 
final rule (64 FR 41522), we indicated that we would allow a temporary 
adjustment to a hospital's FTE resident cap under limited circumstances 
and if certain criteria are met when a hospital assumes the training of 
additional residents because of another hospital's closure. We made 
this change because hospitals had indicated a reluctance to accept 
additional residents from a closed hospital without a temporary 
adjustment to their caps. When we proposed this change 2 years ago, we 
received several comments suggesting that we include lost accreditation 
of a program (that is, a program's closure) in the temporary adjustment 
policy. We explained in our response to these comments (64 FR 41522) 
that we did not believe it was appropriate to expand our policy to 
cover any acts other than a hospital's closure. We made this decision 
because, unless the hospital terminates its Medicare agreement, the 
hospital would retain its statutory FTE cap and could affiliate with 
other hospitals to enable the residents to finish their training.
    It has come to our attention that, despite a hospital's ability to 
affiliate with other hospitals when it shuts down a residency program, 
some hospitals for various reasons do not affiliate before their 
programs close, particularly when the program closes abruptly towards 
the end of the program year (the deadline to submit Medicare 
affiliation agreements is July 1 of the upcoming program year). 
Therefore, in the May 4 proposed rule, we proposed that if a hospital 
that closes its residency training program agrees to temporarily reduce 
its FTE cap, another hospital(s) may receive a temporary adjustment to 
its FTE cap to reflect residents added because of the closure of the 
former hospital's residency training program. For purposes of this 
policy on closed programs, we proposed to define ``closure of a 
hospital residency training program'' as when the hospital ceases to 
offer training for residents in a particular approved medical residency 
training program (proposed Sec. 413.86(g)(8)(i)(B)). The methodology 
for adjusting the caps for the ``receiving hospital'' and the 
``hospital that closed its program'' is described below.
    a. Receiving hospital. We proposed that a hospital(s) may receive a 
temporary adjustment to its (or their) FTE cap to reflect residents 
added because of the closure of another hospital's residency training 
program if--
     The hospital is training additional residents from the 
residency training program of a hospital that closed its program; and
     No later that 60 days after the hospital begins to train 
the residents, the hospital submits to its fiscal intermediary a 
request for a temporary adjustment to its FTE cap, documents that the 
hospital is eligible for this temporary adjustment by identifying the 
residents who have come from another hospital's closed program and have 
caused the hospital to exceed its cap, specifies the length of time the 
adjustment is needed, and submits to its fiscal intermediary a copy of 
the FTE cap reduction statement by the hospital closing the program, as 
specified in paragraph (g)(8)(iii)(B)(2).
    In general, the proposed temporary adjustment criteria are 
reflective of the temporary adjustment criteria for taking on the 
training of displaced residents from closed hospitals. We note that we 
proposed that more than one hospital would be eligible to apply for the 
temporary adjustment, because residents from one closed program may go 
to different hospitals, or they may finish their training at more than 
one hospital. We also noted that only to the extent a hospital would 
exceed its FTE cap by training displaced residents would it be eligible 
for the temporary adjustment.
    Finally, we proposed that hospitals that meet the proposed criteria 
would be eligible to receive temporary adjustments (for cost reporting 
periods beginning on or after October 1, 2001, for direct GME and with 
discharges beginning on or after October 1, 2001 for IME) for training 
the displaced residents from programs that closed even before the 
effective date of this policy. We mentioned this because hospitals may 
have closed programs in the recent past and the residents from the 
closed programs may not have completed their training as of the 
effective date of this policy. For instance, if a 5-year residency 
program, such as surgery, closed on July 1, 1997, the 5th program year 
residents may still be training during this residency year (2001). We 
proposed that if both the receiving hospital(s) and the hospital that 
closed the program in this example follow the criteria described in 
this preamble, the receiving hospital may receive a temporary 
adjustment to its FTE cap for 9 months (October 1, 2001 through June 
30, 2002) to accommodate the 5th year surgery residents. However, we 
noted that hospitals would not be eligible to receive a temporary 
adjustment for

[[Page 39900]]

training the residents until the effective date of this rule (that is, 
October 1, 2001).
    b. Hospital that closed its program(s). We proposed that a hospital 
that agrees to train residents who have been displaced by the closure 
of another hospital's program may receive a temporary FTE cap 
adjustment only if the hospital with the closed program(s)--
     Temporarily reduces its FTE cap by the number of FTE 
residents in each program year training in the program at the time of 
the program s closure. The yearly reduction would be determined by 
deducting the number of those residents who would have been training in 
the program year during each year had the program not closed; and
     No later than 60 days after the residents who were in the 
closed program begin training at another hospital, submits to its 
fiscal intermediary a statement signed and dated by its representative 
that specifies that it agrees to the temporary reduction in its FTE cap 
to allow the hospital training the displaced residents to obtain a 
temporary adjustment to its cap; identifies the residents who were 
training at the time of the program's closure; identifies the hospitals 
to which the residents are transferring once the program closes; and 
specifies the reduction for the applicable program years.
    Unlike the closed hospital policy at Sec. 413.86(g)(8), we proposed 
under this closed program policy (which we proposed to amend 
Sec. 413.86(g)(8) to include), that in order for the receiving 
hospital(s) to qualify for a temporary adjustment to its FTE cap, the 
hospitals that are closing their programs would need to reduce their 
FTE cap for the duration of time the displaced residents would need to 
finish their training. We proposed this change because, as explained 
below, the hospital that closes the program still has the FTE slots in 
its cap, even if the hospital chooses not to fill the slots with 
residents. We believe it is inappropriate to allow an increase to the 
receiving hospital's cap without an attendant temporary decrease to the 
cap of the hospital with the closed program, even if the increase is 
only temporary. We noted that even under the proposed closed program 
policy, the hospital that closes its program may choose instead to 
affiliate with another hospital by July 1 of the next residency year so 
that the residents can more easily finish their training.
    We proposed that the cap reduction for the hospital with the closed 
program would be based on the number of FTE residents in each program 
year who were in the program at the program's closure, and who began 
training at another hospital, rather than the count of residents each 
year at the hospital(s) receiving the temporary adjustment(s). We 
believe it would be too burdensome administratively to require the 
hospital closing the program to keep track of the status of the 
residents when they are training at other hospitals. For instance, Joe 
Smith, a resident who is a PGY 1 when Hospital X closes its pathology 
residency program, may then finish his training at Hospital Y. The 
resident trains for one year at Hospital Y as a PGY 2, but decides to 
drop out of the program before finishing. It would be burdensome to 
require Hospital X to keep track of Joe Smith's status while he is 
training at Hospital Y for purposes of the reduction in Hospital X's 
cap. Therefore, we proposed to ``freeze'' the basis for the reduction 
of the FTE cap of the hospital that closed the program based on the 
count and status of the residents when the hospital closes the program.
    Example: Hospital A, which has a direct GME FTE cap of 20 FTEs 
and an IME FTE cap of 18 FTEs, is experiencing financial 
difficulties and decides to close down its internal medicine 
residency training program effective June 30, 2002. As of June 30, 
2002, Hospital A is training 2 PGY 1s, 4 PGY 2s, and 6 PGY 3s in its 
internal medicine program. Hospitals B, C, and D take on the 
training of the displaced residents. These hospitals are eligible to 
receive temporary adjustments to their FTE caps if they follow the 
proposed criteria stated above. In order for Hospitals B, C, and D 
to receive the temporary adjustments, however, Hospital A must agree 
to reduce its FTE cap. According to the proposed criteria stated 
above, Hospital A's reduction would be:

July 1, 2002 through June 30, 2003

Direct GME FTE cap: 14 FTEs, (20 FTEs cap--2 PGY 2s-4 PGY 3s)
IME FTE cap: 12 FTEs (18 FTEs-2 PGY 2s-4 PGY 3s)
    We note that no downward adjustment for the 6 PGY 3s for either 
cap is necessary since these residents will have completed their 
training in that program by the July 1, 2000 through June 30, 2003 
program year.

July 1, 2003 through June 30, 2004

Direct GME FTE cap: 18 FTEs (20 FTEs cap--2 PGY 3s)
IME FTE cap: 16 FTEs (18 FTEs cap--2 PGY 3s)

July 1, 2004 through June 30, 2005

Direct GME FTE cap: 20 FTEs
IME FTE cap: 18 FTEs

    We also proposed to revise Sec. 412.105(f)(1)(ix) to make the 
provision relating to the adjustment to FTE caps to reflect 
residents affected by closure of hospitals' medical residency 
training programs applicable to determining the IME payment.
    Comment: Several commenters commended us for extending payment of 
IME and direct GME to situations of program closure, explaining that 
this change will help stabilize the GME system and ensure that 
residents can continue their training without imposing financial 
hardship on the institutions that accept them into their programs. One 
commenter also noted that the tradeoff in the FTE resident cap between 
a hospital closing its residency program and the hospital receiving the 
displaced residents seems reasonable. Another commenter stated that 
while the proposed rule more than adequately described the requirements 
and procedures for allowing a hospital to receive a temporary 
adjustment to its FTE caps to reflect residents added because of the 
closure of another hospital's program, the receiving hospital is 
penalized because the 3-year rolling average applies to these 
residents. The commenter noted that, in the first and second year, the 
receiving hospital will be paid one third and two thirds of the costs 
of these displaced FTE residents because of the rolling average, 
although the receiving hospital is paying for these FTE residents at 
full cost. The commenter suggested that a temporary exception should be 
granted to receiving hospitals from the 3-year rolling average in the 
same manner as residents in new programs under Sec. 413.86(g)(5) are 
excluded from the rolling average. The commenter also asked that 
temporary relief should be granted in the IME adjustment with regard to 
the application of the resident-to-bed ratio cap, wherein the relief 
from this cap should be an adjustment to the prior year's resident FTEs 
equal to the increase in the current year's FTEs which is attributable 
to the transferred residents.
    Response: We understand the commenter's concern regarding the 
inclusion of the resident FTEs displaced by the closure of another 
hospital's program in the receiving hospital's rolling average count of 
residents, for both direct GME and IME purposes. In addition, we 
believe that a similar concern also exists in regard to the inclusion 
of residents in the receiving hospital's rolling average calculation 
for residents displaced by the closure of another hospital. Therefore, 
we are revising proposed Sec. 412.105(f)(1)(v) for IME and adding a 
paragraph (vi) to proposed Sec. 413.86(g)(5) for direct GME to specify 
that FTE residents that are displaced by the closure of either another 
hospital or another hospital's program are added after the calculation 
of the rolling average for the receiving

[[Page 39901]]

hospital for the duration of time that those displaced FTE residents 
are training at the receiving hospital.
    In regard to providing temporary relief to the receiving hospital's 
IME resident-to-bed ratio cap for the displaced residents, while we 
understand the commenter's concern about this issue as well, at this 
time we have decided not to allow the exclusion of these displaced 
residents in applying the resident-to-bed ratio cap. Under existing IME 
policy, the receiving hospital may be held to a lower cap in the first 
year of training the displaced residents. However, the receiving 
hospital may benefit from the higher cap in the year following the 
final year of the displaced residents' training. Effective in the first 
year that the receiving hospital takes on the displaced residents, it 
will be capped by the prior year's lower resident-to-bed ratio because 
the displaced residents will not be included in the prior year FTE 
count. However, an increase in the current year's ratio will establish 
a higher cap for the following year. Furthermore, in the last year that 
the receiving hospital is training the displaced residents, a higher 
cap will be established for the following year in which all the 
displaced residents will have left the hospital since they have 
completed their training. Therefore, we believe it is unnecessary to 
exclude displaced residents in applying the resident-to-bed ratio cap. 
While we are not making any changes to address this issue at this time, 
we will consider suggestions for possible changes in the future, if 
warranted.
    Comment: One commenter stated that it is unclear at what rate the 
payments for IME and direct GME will be made for the hospital receiving 
the displaced residents. The commenter asked if Medicare would pay that 
hospital at the same rate that the hospital with the closed program was 
paid for its residents, or would the receiving hospital receive 
Medicare payment at the same rate it currently is paid.
    Response: The receiving hospital will receive payment for the 
displaced residents using its own rates--that is, the same rates as 
those used for residents in its own programs. The receiving hospital 
will use its own bed count for IME payment purposes, and its own PRA 
and Medicare patient load for direct GME payment purposes.
    Comment: One commenter stated that, although the commenter supports 
the proposal for allowing temporary adjustments for residents coming 
from a closed program, the commenter believed that a mechanism should 
be established to ``permanently preserve resident positions, as opposed 
to individual residents,'' so long as there is no increase in the total 
number of FTE residents for which Medicare payment is made.
    Response: In proposing Sec. 413.86(g)(8)(iii), which allows a 
hospital to receive a temporary adjustment to its FTE caps to reflect 
residents added because of the closure of another hospital's program, 
we have attempted to make these regulations consistent with the 
existing regulations at Sec. 413.86(g)(8). These existing regulations 
allow a hospital to receive a temporary adjustment to its FTE caps to 
reflect residents added because of the closure of another hospital. 
Therefore, because the regulations only allow for a temporary cap 
adjustment in situations involving hospital closure, we believe that it 
is appropriate to only allow for a temporary adjustment in situations 
involving program closure, as well.
6. Conforming Change to Regulations Governing Payment to Federally 
Qualified Health Centers (Sec. 405.2468(f))
    We have discovered a technical error in the regulations at 
Sec. 405.2468(f) regarding payment to federally qualified health 
centers (FQHCs) and rural health centers (RHCs) for the costs of 
graduate medical education. Specifically, Sec. 405.2468(f)(6)(ii)(D) 
provides that ``The costs associated with activities described in 
Sec. 413.85(d) of this chapter'' are not allowable graduate medical 
education costs. We recently amended Sec. 413.85 in a final rule (66 FR 
3358, January 12, 2001) regarding Medicare pass-through payment for 
approved nursing and allied health education programs. However, we 
inadvertently did not make a conforming change to 
Sec. 405.2468(f)(6)(ii)(D). Section 405.2468(f)(6)(ii)(D) should read 
``The costs associated with activities described in Sec. 413.85(h) of 
this chapter.'' We proposed to revise Sec. 405.2468(f)(6)(ii)(D) to 
reflect this change.
7. Provisions of the August 1, 2000 Interim Final Rule With Comment 
Period
    The following provisions were included in the August 1, 2000 
interim final rule with comment period. We are presenting a discussion 
of these provisions here in order to respond to the public comments 
received on the provisions and to finalize the rule.
    Section 1886(h) of the Act, as revised by Public Law 105-33, caps 
the number of residents a hospital may count for direct GME and IME. In 
general, the total number of residents in the fields of allopathic or 
osteopathic medicine in a hospital may not exceed the number of such 
FTE residents in the hospital with respect to the hospital's most 
recent cost reporting period ending on or before December 31, 1996. In 
the regulations we published on August 29, 1997 (62 FR 46003), May 12, 
1998 (63 FR 26327), July 31, 1998 (63 FR 40986), and July 30, 1999 (64 
FR 41517), we established special rules for adjusting the FTE resident 
caps for indirect and direct GME for new medical residency programs. 
Public Law 106-113 further revised sections 1886(d) and 1886(h) of the 
Act to allow a hospital's caps to be adjusted if certain additional 
criteria are met.
a. Counting Primary Care Residents on Certain Approved Leaves of 
Absence in Base-Year FTE Count (Section 407(a)(1) of Public Law 106-113 
and New 42 CFR 412.105(f)(1)(xi) and 413.86(g)(9))
    The limit that was placed on the number of residents that a 
hospital may count for purposes of direct GME and IME is based on the 
number of residents in the hospital's most recent cost reporting period 
ending on or before December 31, 1996. In the situation where a primary 
care resident was previously training in a hospital's residency 
program, but was on an approved leave of absence during the hospital's 
most recent cost reporting period ending on or before December 31, 
1996, the hospital's FTE cap may be lower than it would have been had 
the resident not been on an approved leave of absence. Section 407(a) 
of Public Law 106-113 amended section 1886(h)(4)(F) of the Act to 
direct the Secretary to count an individual for purposes of determining 
a hospital's FTE cap, to the extent that the individual would have been 
counted as a primary care resident for purposes of the FTE cap but for 
the fact that the individual was on maternity or disability leave or a 
similar approved leave of absence.
    The statute allows a hospital to receive an adjustment for those 
residents to its individual FTE cap of up to three additional FTE 
residents. We provided that, in order for a hospital to receive this 
adjustment, the leave of absence must have been approved by the 
residency program director to allow the residents to be absent from the 
program and return to the program after the absence. We required that 
no later than 6 months after the date of publication of this interim 
final rule, the hospital must submit a request to the fiscal 
intermediary for an adjustment to its FTE cap and must provide 
contemporaneous documentation of the approval of the leave of absence 
by the residency program director, specific to

[[Page 39902]]

each additional resident that is to be counted for purposes of the 
adjustment. For example, a letter to the resident by the residency 
program director before the resident takes the leave would be 
sufficient documentation of prior approval of the leave of absence.
    Under section 407(a)(3) of Public Law 106-113, this provision is 
effective for direct GME FTE counts with cost reporting periods 
beginning on or after November 29, 1999, and for IME FTE counts, with 
discharges occurring in cost reporting periods beginning on or after 
November 29, 1999.
    We added Secs. 412.105(f)(1)(xi) and 413.86(g)(9) to our 
regulations to incorporate the provisions of section 407(a) of Public 
Law 106-113.
    We received one comment concerning section 407(a)(1) of Public Law 
106-113, as implemented at Secs. 412.105(f)(1)(xi) and 413.86(g)(9), 
concerning the counting of primary care residents in certain approved 
leaves of absence in base-year FTE counts.
    Comment: One commenter asked us to consider allowing hospitals to 
count FTE residents for residents who had been training in an approved 
residency program at a hospital but then left the hospital during the 
1996 base-year and never returned. The commenter stated that the FTE 
slot in which the ``abandoning'' resident vacated sometime in 1996 was 
filled by another resident in 1997 and thereafter, but the hospital has 
never received any direct or indirect GME payment for this FTE slot.
    Response: Section 407(a) of Public Law 106-113 amended section 
1886(h)(4)(F) of the Act to direct the Secretary to count an individual 
for purposes of determining a hospital's FTE cap to the extent that the 
individual would have been counted as a primary care resident for 
purposes of the FTE cap but for the fact that the individual ``was on 
maternity or disability leave or a similar approved leave of absence.'' 
We believe that this provision was not intended to apply to residents 
who leave the program in the base-year and never return. The statutory 
language is quite clear that in order for a hospital to count residents 
in this provision, the resident must have been on an ``approved leave 
of absence.'' A ``leave of absence'' necessarily translates to a 
resident being away and then returning to the hospital at which the 
resident had been training.
b. Adjustments to the FTE Cap for Rural Hospitals (Section 407(b)(1) of 
Public Law 106-113 and 42 CFR 412.105(f)(l)(iv) and 413.86(g)(4))
    Public Law 105-33 included several provisions with the intent of 
encouraging physician training and practice in rural areas. Section 
1886(h)(4)(H)(i) of the Act, as added by section 4623 of Public Law 
105-33, directed the Secretary, in promulgating rules for the purpose 
of the FTE cap, to give special consideration to facilities that meet 
the needs of underserved rural areas. Consistent with the intent of 
this provision, section 407(b) of Public Law 106-113 provides a 30-
percent expansion of a rural hospital's direct and indirect FTE count 
for purposes of establishing the hospital's individual FTE cap. 
Specifically, section 407(b) provided that, effective for direct GME 
with cost reporting periods beginning on or after April 1, 2000, and 
for IME, with discharges occurring on or after April 1, 2000, the FTE 
count may equal 130 percent of the number of unweighted residents the 
rural hospital counted in its most recent cost reporting period ending 
on or before December 31, 1996.
    For example, if a hospital located in a rural area had 10 
unweighted FTEs for its count for both direct GME and IME in its most 
recent cost reporting period ending on or before December 31, 1996, 
under this new provision the hospital would have a FTE cap of 13 
unweighted FTEs, instead of 10 unweighted FTEs, because the hospital is 
located in a rural area. The revised FTE cap is equal to 130 percent of 
the number of unweighted residents in its most recent cost reporting 
period ending on or before December 31, 1996. The rural hospital's new 
FTE cap, effective April 1, 2000, is now 13 FTEs. However, if a 
hospital located in a rural area had zero unweighted FTEs for its count 
for both direct GME and IME in its most recent cost reporting period 
ending on or before December 31, 1996, under this new provision, this 
hospital would receive no adjustment to its FTE cap (130 percent of 
zero is zero FTEs).
    We incorporated the provision of section 407(b) of Public Law 106-
113 in Secs. 412.105(f)(1)(iv) and 413.86(g)(4). We did not receive any 
comments on this provision.
c. Rural Track FTE Limitation for Purposes of GME and IME for Urban 
Hospitals that Establish Separately Accredited Approved Medical 
Programs in a Rural Area (Section 407(c) of Public Law 106-113 and new 
42 CFR 412.105(f)(1)(x) and 413.86(g)(11))
    In order to encourage the training of physicians in rural areas, 
section 407(c) of Public Law 106-113 amended section 1886(h)(4)(H) of 
the Act to add a provision that in the case of a hospital that is not 
located in a rural area but establishes separately accredited approved 
medical residency training programs (or rural tracks) in a rural area 
or has an accredited training program with an integrated rural track, 
an adjustment may be made to the hospital's cap on the number of 
residents. For direct GME, the amendment applies to payments to 
hospitals for cost reporting periods beginning on or after April 1, 
2000; for IME, the amendment applies to discharges occurring on or 
after April l, 2000.
    Section 407(c) of Public Law 106-113 did not define ``rural 
tracks'' or an ``integrated rural track,'' nor are these terms defined 
elsewhere in the Social Security Act or in any applicable Federal 
regulations. Currently, there are a number of accredited residency 
programs, particularly 3-year primary care residency programs, in which 
residents train for 1 year of the program at an urban hospital and are 
then rotated for training for the other 2 years of the 3-year program 
to a rural facility. These separately accredited ``rural track'' 
programs are identified by the Accreditation Council of Graduate 
Medical Education (ACGME) as ``1-2'' rural track programs. Accordingly, 
we implemented section 407(c) to address these ``1-2'' programs. In 
addition, we implemented section 407(c) to account for other programs 
that are not ``1-2'' programs but which include rural training 
portions.
    As stated above, since there is no existing definition of ``rural 
track'' or ``integrated rural track,'' we defined at Sec. 413.86(b) a 
``rural track'' and an ``integrated rural track'' as an approved 
medical residency training program established by an urban hospital in 
which residents train for a portion of the program at the urban 
hospital and then rotate for a portion of the program to a rural 
hospital(s) or to a rural nonhospital site(s). We noted that ``rural 
track'' and ``integrated rural track,'' for purposes of this 
definition, are synonymous.
    We amended Sec. 413.86 to add paragraph (g)(11) (and amended 
Sec. 412.105 to add paragraph (f)(1)(x)) to specify that, for direct 
GME, for cost reporting periods beginning on or after April 1, 2000, 
(or, for IME, for discharges occurring on or after April 1, 2000), an 
urban hospital that establishes a new residency program, or has an 
existing residency program, with a rural track (or an integrated rural 
track) may include in its FTE count residents in those rural tracks, in 
addition to the residents subject to the FTE cap at Sec. 413.86(g)(4). 
An urban hospital may count the residents in the rural track up to a 
``rural track FTE limitation'' for that

[[Page 39903]]

hospital. We defined this rural track FTE limitation at Sec. 413.86(b) 
as the maximum number of residents training in a rural track residency 
program that an urban hospital may include in its FTE count, that is in 
addition to the number of FTE residents already included in the 
hospital's FTE cap.
    Generally, the rural track policy is divided into two categories: 
Rural track programs in which residents are rotated to a rural area for 
at least two-thirds of the duration of the program; and rural track 
programs in which residents are rotated to a rural area for less than 
two-thirds of the duration of the program. These two categories are 
then subdivided according to where the residents are training in the 
rural area; the residents may be trained in a rural hospital or the 
residents may be trained in a rural nonhospital site. To account for 
rural track residency programs with rural rotations that have program 
lengths greater than or less than 3 years, or that are not ``1-2'' 
programs, we specified ``two-thirds of the length of the program,'' 
instead of ``2 out of 3 program years,'' as a qualification to count 
FTEs in the rural track.
    In the interim final rule with comment period, we specified that 
urban hospitals that wish to count FTE residents in rural tracks, up to 
a rural track FTE limitation, must comply with the conditions discussed 
below:
(1) Rotating Residents for at Least Two-Thirds of the Program to a 
Rural Hospital(s)
    In the August 1, 2000 interim final rule with comment period, we 
specified at Sec. 413.86(g)(11)(i) that if an urban hospital rotates 
residents in the rural track program to a rural hospital(s) for at 
least two-thirds of the duration of the program, the urban hospital may 
include those residents in its FTE count for the time the rural track 
residents spend at the urban hospital. The urban hospital may include 
in its FTE count those residents in the rural track training at the 
urban hospital, not to exceed its rural track FTE limitation, 
determined as follows:
     For the first 3 years of the rural track's existence, the 
rural track FTE limitation for each urban hospital will be the actual 
number of FTE residents training in the rural track at the urban 
hospital.
     Beginning with the fourth year of the rural track's 
existence, the rural track FTE limitation is equal to the product of: 
(1) The highest number of residents in any program year who, during the 
third year of the rural track's existence, are training in the rural 
track at the urban hospital or the rural hospital(s) and are designated 
at the beginning of their training to be rotated to the rural 
hospital(s) for at least two-thirds of the duration of the program; and 
(2) the number of years those residents are training at the urban 
hospital.
    We utilized the term ``designated'' at Sec. 413.86(g)(11)(i) (as 
well as at Secs. 413.86(g)(11)(ii) and (iv)) to refer to the 
calculation of the rural track FTE limitation. ``Designated'' means 
that the residents must actually have enrolled in that rural track 
program to rotate for a portion of the rural track program to a rural 
area (either rural hospital(s) or rural nonhospital site(s)). To be 
counted as an FTE in this first scenario, these enrolled residents must 
actually rotate for at least two-thirds of the duration of the program 
to a rural hospital(s). If a resident, at the beginning of his or her 
training, intends to train in the rural area for at least two-thirds of 
the duration of the program, but ultimately never does so, this 
resident would be proportionately excluded from the urban hospital's 
rural track FTE limitation.
    We noted that if the residents in the rural track are rotating to a 
rural hospital(s), the rural hospital(s) may be eligible to count the 
residents as part of its FTE count. If the rural track residency 
program is a new residency program as specified in redesignated 
Sec. 413.86(g)(12), the rural hospital may be eligible to receive an 
FTE cap adjustment for those residents training in the rural track for 
the time those residents are training at the rural hospital(s), in 
accordance with the provisions of existing Sec. 413.86(g)(6)(iii). If 
the rural track residency program is an existing residency program, a 
rural hospital may be eligible to count the FTE residents training in 
the rural track at the rural hospital(s), in accordance with the 
provisions of Sec. 413.86(g)(4), as amended in the interim final rule 
with comment period to implement section 407(b)(1) of Public Law 106-
113.
(2) Rotating Residents for at Least Two-Thirds of the Program to a 
Rural Nonhospital Site
    In the August 1, 2000 interim final rule with comment period, we 
specified at Sec. 413.86(g)(11)(ii) that if an urban hospital rotates 
residents in the rural track program to a rural nonhospital site(s) for 
at least two-thirds of the duration of the program, the urban hospital 
may include those residents in its FTE count, subject to the 
requirements under existing Sec. 413.86(f)(4). The urban hospital may 
include in its FTE count those residents in the rural track, not to 
exceed its rural track FTE limitation, determined as follows:
     For the first 3 years of the rural track's existence, the 
rural track FTE limitation for each urban hospital will be the actual 
number of FTE residents training in the rural track at the urban 
hospital and the rural nonhospital site.
     Beginning with the fourth year of the rural track's 
existence, the rural track FTE limitation is equal to the product of: 
(1) The highest number of residents in any program year who, during the 
third year of the rural track's existence, are training in the rural 
track at the urban hospital and are designated at the beginning of 
their training to be rotated to a rural nonhospital site(s) for at 
least two-thirds of the duration of the program and the rural 
nonhospital site(s); and,(2) the number of years in which the residents 
are expected to complete each program based on the minimum accredited 
length for the type of program.
    We note that we specified at Sec. 413.86(g)(11)(ii) that an urban 
hospital may include in its FTE count those residents in the rural 
track rotating to a rural nonhospital site, subject to the requirements 
under existing Sec. 413.86(f)(4). Section 413.86(f)(4) provides, in 
part, that a hospital that incurs ``all or substantially all'' of the 
costs of training residents in a nonhospital site may include those 
residents in determining the number of FTE residents (not to exceed the 
FTE cap) for that hospital. Under this rural track policy, where the 
urban hospital rotates residents for at least two-thirds of the 
residency program to a rural nonhospital site, the urban hospital would 
be eligible to include in its FTE count residents training in the rural 
track up to its rural track FTE limitation, but the urban hospital must 
still reimburse the rural nonhospital site for the costs of training 
those residents, as specified under Sec. 413.86(f)(4). In the August 1, 
2000 interim final rule with comment period (66 FR 47034), we included 
an example of application of this policy.
(3) Rotating Residents for Less Than Two-Thirds of the Program to a 
Rural Hospital(s)
    In the August 1, 2000 interim final rule with comment period, we 
specified at Sec. 413.86(g)(11)(iii) that if an urban hospital rotates 
residents in the rural track program to a rural hospital(s) for periods 
of time that are less than two-thirds of the duration of the program, 
the urban hospital may not include those residents in its FTE count, 
nor may the urban hospital include those residents as part of its rural 
track FTE

[[Page 39904]]

limitation. However, we noted that, in this scenario, if the rural 
track residency program is a new residency program as specified in 
redesignated Sec. 413.86(g)(12), the rural hospital may be eligible to 
receive an FTE cap adjustment for those residents training in the rural 
track, in accordance with the provisions of existing 
Sec. 413.86(g)(6)(iii). If the rural track residency program is an 
existing residency program, a rural hospital may count the FTE 
residents training in the rural track at the rural hospital(s), in 
accordance with the provisions of Sec. 413.86(g)(4), as amended, to 
incorporate the provisions of section 407(b)(1) of Public Law 106-113.
    We are not permitting an urban hospital to count the time of 
residents training at the urban hospital in a rural track rotating to a 
rural hospital(s) for less than two-thirds the duration of the program 
(either as part of the urban hospital's FTE count or as part of its 
rural track FTE limitation), because to do so would inappropriately 
allow the urban hospital to circumvent the FTE caps by creating a new 
program with minimal training in a rural track. However, in this 
situation, like the other three provisions that concern the training of 
residents in rural areas, we indicated that we will allow Medicare 
payment for the rural portion of the training to the rural hospital.
(4) Rotating Residents for Less Than Two-Thirds of the Program to a 
Rural Nonhospital Site
    In the August 1, 2000 interim final rule with comment period, we 
specified at Sec. 413.86(g)(11)(iv) that if an urban hospital rotates 
residents in the rural track program to a rural nonhospital site(s) for 
periods of time that are less than two-thirds of the duration of the 
program, the urban hospital may include those residents in its FTE 
count, subject to the requirements under existing Sec. 413.86(f)(4). 
The urban hospital may include in its FTE count those residents in the 
rural track, not to exceed its rural track FTE limitation, determined 
as follows:
     For the first 3 years of the rural track's existence, the 
rural track FTE limitation for the urban hospital will be the actual 
number of FTE residents training in the rural track at the rural 
nonhospital site.
     Beginning with the fourth year of the rural track's 
existence, the rural track FTE limitation is equal to the product of: 
(a) The highest number of residents in any program year who, during the 
third year of the rural track's existence, are training in the rural 
track at the rural nonhospital site(s); and (b) the length of time in 
which the residents are being trained at the rural nonhospital site(s).
    We noted that, in this situation, an urban hospital would not be 
able to count the FTE for the rural track resident while the resident 
is training at the urban hospital. The rural track FTE count and the 
rural track FTE limitation for the urban hospital would be limited to 
account for the residents training at the rural nonhospital site.
    As in the second scenario at Sec. 413.86(g)(11)(ii), we specified 
at Sec. 413.86(g)(11)(iv) that an urban hospital may include in its FTE 
count those residents in the rural track rotating to a rural 
nonhospital site, subject to the requirements under Sec. 413.86(f)(4). 
Under the rural track policy, where the urban hospital rotates 
residents for less than two-thirds of the residency program to a rural 
nonhospital site, the urban hospital would be eligible to include in 
its FTE count residents training in the rural track up to its rural 
track FTE limitation, but the urban hospital must still reimburse the 
rural nonhospital site for the costs of training those residents, as 
specified under Sec. 413.86(f)(4).
    We noted that, in this last scenario, we are allowing the urban 
hospital to receive a rural track FTE limitation even in situations 
where it is rotating residents to a rural area for a minimal period of 
time (less than two-thirds the duration of the program). However, we 
believe that this last scenario can be distinguished from the third 
scenario in which the urban hospital is again rotating residents to a 
rural area for a minimal portion of the program but to a rural hospital 
instead of a rural nonhospital site. In the third scenario, we allow 
Medicare payment to go to the rural hospital for the portion of the 
urban hospital program that involves rural training (but not to the 
urban hospital, if the rural hospital is receiving an FTE cap 
adjustment for that training). However, in the last scenario, we allow 
the urban hospital to include the rural track residents in its FTE 
count (and as part of its rural track FTE limitation), based on how 
long it rotates the residents to the rural nonhospital site (and also 
incurs all or substantially all of the training costs). We do not 
believe that the urban hospital can circumvent its FTE cap in this last 
scenario because it will only count the rural track residents based on 
the portion of training in the rural nonhospital site. In the interim 
final rule with comment period (66 FR 47035), we included an example of 
the last scenario.
(5) Conditions That Apply to All Urban Hospitals
    In the August 1, 2000 interim final rule with comment period, we 
specified that all urban hospitals that wish to count FTE residents in 
rural tracks, not to exceed their respective rural track FTE 
limitations, must also comply with each of the following conditions, as 
stated at Secs. 413.86(g)(11)(v) and (vi):
     A hospital may not include in its FTE count residents who 
are training in a rural track residency program that were already 
included as part of the hospital's FTE cap (if the rural track program 
was in existence during the hospital's most recent cost reporting 
period ending on or before FY 1996).
     A hospital must base its count of residents in a rural 
track on written contemporaneous documentation that each resident 
enrolled in a rural track program at the urban hospital intends to 
rotate for a portion of the residency program to a rural area. For 
example, written contemporaneous documentation might be a letter of 
intent signed and dated by the rural track residency program director 
and the resident at the time of the resident's entrance into the rural 
track program as a PGY 1.
     All residents who are included by the hospital as part of 
its FTE count (not to exceed its rural track FTE limitation) must 
ultimately train in the rural area.
     If we find that residents who are included by the urban 
hospital as part of its FTE count did not actually complete the 
training in the rural area, we will reopen the urban hospital's cost 
report within the 3-year reopening period (as specified in 
Sec. 405.1885) and adjust the hospital's Medicare GME payments (and, 
where applicable, the hospital's rural track FTE limitation).
    We received several comments regarding the provisions of section 
407 of Public Law 106-113 implemented in the August 1, 2000 interim 
final rule with comment period.
    Comment: One commenter cited studies that found that more than half 
of residents with as little as 3 months of rural training became rural 
physicians, and, therefore, to best serve the intent of the legislation 
and significantly increase the number of rural physicians, we should 
fully fund FTEs with less than two-thirds total training in rural 
areas.
    Response: Section 1886(h)(4)(H)(iv) of the Act, as added by section 
407(c) of Public Law 106-113, provides for adjustments to the FTE cap 
``[i]n the case of a hospital that is not located in a rural area but 
establishes separately accredited approved medical residency training 
programs (or rural tracks) in a[]

[[Page 39905]]

rural area * * *.'' Thus, in order for a hospital to receive an 
adjustment under this provision, the training program must be 
separately accredited. The ACGME has established criteria to separately 
accredit programs that involve training in rural areas; under these 
criteria, a training program may be separately accredited if residents 
in the program train for at least 2 years of the 3-year program at a 
rural facility. Currently, the ACGME does not separately accredit a 
program as a rural track program or a program in a rural area unless it 
meets this ``1-2'' condition. We make an adjustment to the FTE cap 
under the rural track provision only if a program is separately 
accredited, and in order to be separately accredited, the program must 
meet ACGME's ``1-2'' criteria. We are amending the regulations at 
Sec. 413.86 by adding paragraph (g)(11) to reflect this policy .
    Furthermore, we believe that incorporating the ACGME's criteria 
reasonably identifies the situations in which an adjustment to the FTE 
cap under the rural track provision is warranted. We believe that it is 
important to limit adjustments under this provision to situations in 
which residents receive a significant amount of training in rural 
areas. While we certainly agree that post-residency physician retention 
in rural areas is important, we believe that it is also important to 
prevent hospitals from receiving adjustments to the FTE cap in 
situations when an adjustment is not warranted. We believe that, if an 
urban hospital could receive an adjustment to its FTE cap by providing 
only a nominal amount of training in a rural area, then hospitals might 
be able to inappropriately circumvent the FTE caps. Thus, our policy 
reflects the requirements of the statute as well as a balancing of 
considerations (permitting adjustments for hospitals that establish 
programs that provide a significant amount of training in rural areas, 
and preventing adjustments for hospitals that do not warrant an 
adjustment).
    Comment: One commenter noted that, for cost reporting periods 
beginning on or after April 1, 2000, section 407 of Public Law 106-113 
allows rural hospitals to increase their FTE resident caps by 30 
percent and urban hospitals with rural training tracks to count those 
residents in rural tracks. The commenter had two concerns: (1) What 
happens to rural track programs that were in existence between January 
1, 1997 and April 1, 2000; and (2) if the intent of the rural track 
provision is to encourage training in rural areas, then rural track 
programs in existence between January 1, 1997 and April 1, 2000 should 
also be permitted to expand by 30 percent.
    Response: Section 1886(h)(4)(F) of the Act, as added by section 
407(b) of Public Law 106-113, and as implemented at Secs. 413.86(g)(4) 
and 412.105(f)(1)(iv), provides for a 30-percent expansion to a rural 
hospital's direct and indirect FTE counts for purposes of establishing 
the hospital's individual FTE cap. Section 407(c) provides for an 
adjustment to the FTE cap of urban hospitals for training residents in 
rural areas. Section 407(b) clearly only applies to rural hospitals, 
and not to urban hospitals, regardless of whether or not the urban 
hospitals train residents in rural areas. Therefore, while the general 
intent of the provisions at section 407 is to encourage training in 
rural areas, only those rural hospitals that have a FTE resident cap 
based on the count of residents in the hospital's cost reporting period 
ending on or before December 31, 1996, may qualify for a 30-percent 
increase to that FTE cap under the amendments made by section 407(b).
    To address the commenter's uncertainty concerning what happens to 
rural track programs that were in existence between January 1, 1997 and 
April 1, 2000, we point to our language at Secs. 413.86(g)(11) and 
412.105(f)(1)(x) which states that for cost reporting periods beginning 
on or after April 1, 2000, ``an urban hospital that establishes a new 
residency program, or has an existing residency program, with a rural 
track (or an integrated rural track) may include in its FTE count 
residents in those tracks * * *'' (emphasis added). Thus, urban 
hospitals with rural tracks that were in existence between January 1, 
1997 and April 1, 2000, and continue to be in existence afterApril 1, 
2000, may be eligible for Medicare payment under this provision. We 
note that urban hospitals with rural tracks that were established 
before January 1, 1997, and continued to exist after April 1, 2000, may 
be eligible for payment under this rural track provision, as well.
    We note that we have received questions from the provider industry 
regarding the application of the rural track FTE limitation and rural 
track FTE count to hospitals with rural track programs that have 
already been in existence before April 1, 2000. Generally, the 
methodology at Sec. 413.86(g)(11) states that the actual count of 
residents for the first 3 years of the rural track's existence is to be 
used as the hospital's rural track FTE limitation, and beginning with 
the fourth year, the rural track FTE limitation is determined based on 
the number of residents training in the rural track in the third year 
of the program's existence. However, if a rural track program has been 
in existence for at least 3 years prior to April 1, 2000, the provision 
regarding using the actual count of residents in the first 3 years of 
the program would not apply. Rather, for such a program, the rural 
track FTE limitation would take effect immediately on April 1, 2000. 
The limitation would be based on the highest number of residents in any 
program year training in the rural track in the third year of the 
program, depending on the amount of time the residents spent in the 
rural area, subject to the regulations at Sec. 413.85(g)(11)(i) through 
(iv). It would be the responsibility of the hospital to provide the 
necessary information regarding the third year of the program to the 
fiscal intermediary. For example, if the third year of the rural 
track's existence is July 1, 1997 to June 30, 1998, the rural track FTE 
limitation would be based on the highest number of residents in any 
program year in 1997-1998 training year. The urban hospital may begin 
to count the additional FTEs up to its rural track FTE limitation in 
its cost reporting period beginning on or after April 1, 2000 for 
direct GME, and for discharges occurring on or after April 1, 2000 for 
IME.
    Comment: One commenter noted that the interim final rule with 
comment period states that ``all residents that are included by the 
hospital as part of its FTE count must ultimately train in the rural 
area.'' The commenter expressed concern that we are requiring hospitals 
to designate specific individuals, rather than FTEs, and that basing 
payment on individuals rather than FTEs would set a poor precedent. The 
commenter further stated that, while specific individuals may not 
remain in a program, hospitals should be permitted to fill these slots 
with FTEs and receive payment.
    Response: The commenter is concerned with the provision at 
Sec. 413.86(g)(11)(v)(C), which states that all residents that are 
included by the hospital as part of its FTE count under this provision 
must ultimately train in the rural area. As the commenter correctly 
assesses, this particular provision would link the rural track policy 
to specific individual residents, rather than FTEs. We made this link 
to individuals rather than FTEs because we believe the additional 
provision at Sec. 413.86(g)(11)(v)(C) (as well as the provision at 
Secs. 413.86(g)(11)(v)(B)) was necessary in order to ensure that urban 
hospitals did not count additional FTE

[[Page 39906]]

residents who did not actually rotate at any time to a rural area.
    However, we understand the commenter's concern about permitting 
hospitals to fill slots with FTEs that are open because individuals did 
not remain in the program. We agree that where a hospital fills a 
vacated FTE slot in a rural 1-2 program with another resident, it would 
be consistent with the intent of the rural track provision to allow the 
urban hospital to count the time of the resident who left the training 
program. Accordingly, we are amending the regulations at 
Sec. 413.86(g)(11)(v)(C) to allow for the counting of the resident's 
time at the urban hospital where, for example, a resident who just 
completed her PGY1 year at the urban hospital decides to drop out of 
the program, and then the urban hospital fills the vacated FTE slot 
with another PGY2 resident who then continues and completes the rural 
portion of the rural track program. We note that we would not allow for 
the counting of the time at the urban hospital for the first year of 
training for that resident who left the program where the urban 
hospital fills the vacated FTE slot with another PGY1 resident who 
first begins to train in the urban hospital, since, in effect, this 
would result in double counting one FTE at the urban hospital without 
the required amount of training occurring in the rural area.
    Comment: One commenter expressed concern with the provision at 
Sec. 413.86(g)(11)(v)(A) that states ``an urban hospital may not 
include in its rural track FTE limitation or FTE count residents who 
are training in a rural track residency program that were already 
included as part of the hospital's FTE cap.'' The commenter stated that 
this provision fails to account for the fact that many hospitals may 
have ``backed out'' residents training time in rural sites from their 
base year FTE cost reports. The commenter stated further that this 
provision may be interpreted by cost report accountants to mean that 
appeals to include FTEs that were excluded by Public Law 105-33 are 
prohibited.
    Response: We believe the commenter is confusing the provision at 
Sec. 413.86(g)(11)(v)(A), that an urban hospital may not include in its 
rural track FTE limitation or rural track FTE count residents who are 
training in a rural track residency program that were already included 
as part of the hospital's FTE cap, and the policy contained in section 
4623 of Public Law 105-33, as implemented at Secs. 412.105(f)(1)(iv) 
and 413.86(g)(4), which places a limit on the count of residents, or 
hospitals' FTE caps. The intent of the provision at 
Sec. 413.86(g)(11)(v)(A) is to encourage more residency training in 
rural areas by providing for Medicare payment to an urban hospital for 
FTE residents who are training in a rural area and are not already 
included as part of the hospital's FTE cap. Whether or not there are 
many hospitals that have ``backed out'' resident training time in rural 
sites from their base year FTE cost reports is irrelevant to this rural 
track requirement. The possible mistaken exclusion of the count of 
resident FTEs spent in rural settings is an issue relevant to the 
determination of a hospital's initial FTE cap as provided for at 
Secs. 412.105(f)(1)(iv) and 413.86(g)(4). The rural track requirement 
at Sec. 413.86(g)(11)(v)(A) was not intended to provide for adjustments 
to reflect FTEs that were excluded from the FTE cap.
    With regard to rural training, generally, and the determination of 
a hospital's FTE cap under Secs. 412.105(f)(1)(iv) and 413.86(g)(4), a 
FTE resident should not have been included in the hospital's FTE cap to 
the extent that, in that cost reporting year, the resident was rotating 
to another rural hospital, or if the resident was rotating to a rural 
nonhospital to which the urban hospital was not paying all or 
substantially all of the costs of training (see Sec. 413.86(f)(3)).
    To clarify the intent of the requirement that ``an urban hospital 
may not include in its rural track FTE limitation or FTE count 
residents who are training in a rural track residency program that were 
already included as part of the hospital's FTE cap,'' we are providing 
the following example:
     Assume there are 10 unweighted FTE residents training at 
an urban Hospital A in the hospital's most recent cost reporting period 
ending on or before December 31, 1996, thereby establishing Hospital 
A's FTE cap at 10.
     In July 2002, Hospital A starts a rural training track 
program. In addition to devoting 2 out of its 10 FTE slots to the rural 
track, Hospital A recruits an additional 2 FTEs to participate in the 
rural track, for a total of 12 FTEs to be trained in that cost 
reporting year.
     These 4 FTEs will complete 1 year of training at Hospital 
A and 2 years of training at a rural nonhospital site. This type of 
program is modeled after the scenario outlined at 
Sec. 413.86(g)(11)(ii), where the urban hospital may include in its FTE 
count the FTEs in the rural track at the urban hospital and at the 
rural nonhospital site. (Hospital A is complying with the requirements 
at Sec. 413.86(f)(4) regarding the counting of residents in nonhospital 
sites).
    However, when calculating the rural track FTE limitation in the 
fourth year of the rural track's existence, Hospital A may not include 
in its rural track FTE limitation those FTEs that were already included 
as part of the hospital's initial FTE cap. Two of the hospital's four 
FTEs training in the rural track were already included in the 
hospital's FTE cap. Therefore, beginning July 2002, only two FTEs may 
be included to determine the hospital's rural track FTE limitation, as 
well as its rural track FTE count. Since it is the two FTEs that 
Hospital A added when it started the rural track that have caused the 
hospital to exceed its FTE cap, only two FTEs may be counted above the 
FTE cap for the hospital's rural track FTE count and limitation. 
However, we note that the other two FTEs training in the rural track 
that were not included as part of the hospital's rural FTE count and 
limitation because they had already been included as part of the 
hospital's FTE cap, may still be counted by the hospital in its general 
FTE count, according to Secs. 412.105(f) and 413.86(f).
    Comment: One commenter requested that, since rural hospitals often 
do not have the resources or infrastructure to claim their GME costs on 
a Medicare cost report, we should revise the regulations to allow urban 
hospitals to claim the resident FTEs training at the rural hospitals, 
as long as the urban hospitals are providing ``adequate funding'' to 
the rural hospital, similar to our Medicare policy on nonhospital 
settings.
    Response: In regard to the request to allow urban hospitals to 
claim the FTEs training in rural hospitals, while we understand that it 
is not uncommon for urban hospitals to incur the costs of training 
residents in rural hospitals because the rural hospitals cannot incur 
the costs themselves, there is longstanding policy that prohibits one 
hospital from claiming the training time of FTEs training at another 
hospital. First, section 1886(h)(4)(B) of the Act states that the rules 
governing the direct GME computation of count of the number of FTE 
residents ``shall take into account individuals who serve as residents 
for only a portion of a period with a hospital or simultaneously with 
more than one hospital.'' Accordingly, the September 4, 1990 Federal 
Register (55 FR 36065) states that ``* * * the other hospital is 
required to include the portion of time the resident spent at its 
facility in its FTE count consistent with Sec. 413.86(f).'' Further, 
the regulations at Sec. 413.86(f)(2) state that ``No individual may be 
counted as more than one FTE * * *. [I]f a resident spends time in more 
than one hospital * * * the

[[Page 39907]]

resident counts as partial FTE based on the proportion of time worked 
at the hospital to the total time worked * * *.'' Therefore, even 
though the urban hospital incurs the training costs and the rural 
hospital does not claim the FTEs for Medicare direct GME and IME 
payment purposes, the urban hospital is precluded from claiming any 
FTEs training at the rural hospital (or any other hospital, for that 
matter). The commenter is correct in stating that a hospital may count 
the time residents spend in nonhospital settings if they comply with 
the criteria at Sec. 413.86(f)(4). However, this regulation implements 
statutory provisions (sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of 
the Act), which specifically provide for Medicare direct GME and IME 
payment to be made to hospitals for training residents in nonhospital 
settings.
    Comment: One commenter objected to the policy in the interim final 
rule with comment period that the terms ``rural track'' and 
``integrated rural track'' are synonymous. The commenter (a hospital) 
believed that we have the authority to develop a new definition for 
``integrated rural track'' based on our interpretations of 
congressional intent, and we should not wait for further clarification 
from Congress at the expense of the commenter's particular allopathic 
family practice residency program. The commenter described this program 
as one in which the residents train in the rural setting for 
approximately 7 months out of a 3-year program, and for the remainder 
of the program when the residents spend training in the urban setting, 
the residents treat rural patients. The commenter proposed the 
following new definition for integrated rural track: ``Accredited 
Training Program with an Integrated Rural Track--refers to an 
accredited program that provides at least 6 months of training at a 
rural location in addition to 2 years of rural training at an urban 
location. The 6 months of rural training should be conducted as part of 
all 3 years of training. The program should also establish a continuity 
of care with patients in a rural area for at least one program year.''
    Response: When we implemented this provision on August 1, 2000, we 
did so based on discussions with the Accreditation Council for Graduate 
Medical Education (ACGME), which accredits rural track programs. The 
ACGME specifically identifies and separately accredits programs with 1 
year of training in an urban hospital and 2 years of training in a 
rural facility as ``rural tracks.'' However, the ACGME explained that 
it did not have a separate definition of ``integrated rural track'' 
and, in particular, did not separately classify programs with portions 
of rural training of less than 2 years as ``integrated rural tracks''. 
In response to questions raised on this provision, we have followed up 
with the ACGME to confirm whether a definition of, or criteria for 
identifying programs with, ``integrated rural tracks'' had been 
established. We were informed that the term ``integrated rural track'' 
is not, and never was, a term that is used by the ACGME in accrediting 
its programs. Other than the 1-2 programs that specifically incorporate 
2 years of rural training, the ACGME does not grant unique 
accreditation to programs with a rural focus, nor do any of the other 
accreditation organizations listed at Sec. 415.152.
    In addition, we do not believe it is administratively feasible for 
us to review documentation and confirm that the training at the urban 
hospital, as suggested by the commenter, is rural in nature, based on 
the patient load treated by the residents at the urban hospital. We 
currently do not have a way of tying patient data to the residents that 
treat them. Accordingly, for purposes of this policy, until we believe 
we can appropriately categorize and define rural tracks and integrated 
rural tracks separately, we will continue to define these terms 
synonymously. We remain open to adopting another definition of a 
separately accredited training program, and we welcome suggestions for 
definitions that would be administratively feasible to apply.
    Comment: One commenter suggested that we add a fifth scenario to 
those already described at Sec. 413.86(g)(11). The commenter proposed 
the following regulation text:

    Rotating Residents of an Accredited Training Program with an 
Integrated Rural Track to a Rural Nonhospital Site--If an urban 
hospital rotates residents in an accredited training program with an 
integrated rural track to a rural nonhospital site throughout all 3 
years of training, the urban hospital may include those residents in 
its FTE count, subject to the requirements under existing 
Sec. 413.86(g)(4). The urban hospital may include in its FTE count 
those residents in the rural track, not to exceed its rural track 
FTE limitation, determined as follows:
    (A) For the first 3 years of the integrated rural track's 
existence, the rural track FTE limitation for each urban hospital 
will be the actual number of FTE residents training in the rural 
track at the urban hospital and the rural nonhospital site.
    (B) Beginning with the fourth year of the integrated rural 
track's existence, the rural track FTE limitation is equal to the 
product of:
    (1) The highest number of residents in any program year who, 
during the third year of the integrated rural track's existence, are 
training in the integrated rural track at the urban hospital and are 
designated at the beginning of their training to be rotated to a 
rural nonhospital site throughout all 3 years of training, and
    (2) The number of years in which the residents are expected to 
complete each program based on the minimum accredited length for the 
type of program.
    (C) This would apply to accredited training programs with 
integrated rural tracks that were in existence prior to 1997.

    The commenter explained that this language is designed to address 
the unique program at the commenter's hospital, and it also is date 
sensitive so that newer programs would be required to comply with the 
existing criteria in the existing regulations.
    Response: We have concerns about the commenter's proposal. First, 
the commenter assumes a separate definition of ``integrated rural 
track,'' which, as explained above, we currently do not have. Even if 
we were to adopt such a change in policy, the cut-off date of 1997 in 
paragraph (C) of the commenter's proposed changes seems arbitrary; 
there is nothing in the statute that would serve as a basis to simply 
grandfather existing ``integrated rural track'' programs and not 
provide for new ones post-1997. Accordingly, we are not adopting such a 
change in our rural track policy as the one described by the commenter.
    Comment: One commenter thought that if a hospital's rural track 
program has been in existence since 1993, then the 4th program year is 
1997. The commenter explained that when the FTE cap went into effect, 
the hospital was capped at 15 FTEs. The hospital subsequently added 
another three residents at its own expense. The commenter stated that 
it interprets Sec. 413.86(g)(11)(v)(A) to mean that the hospital would 
only be able to count the additional three FTE residents for the rural 
track count. The commenter urged us to reconsider this language as it 
relates to hospitals with only one residency program, because the 
commenter was unsure whether or not all the residents in the program 
count toward the rural track FTE count. The commenter believed that for 
hospitals with only one residency program that existed prior to 1996, 
all rural track residents included in the original hospital FTE cap 
should be counted toward the rural FTE count.
    Response: The commenter correctly interprets the intent of the 
regulation at Sec. 413.86(g)(11)(v)(A), which states that only those 
FTEs in the rural track that were not already counted as part of the

[[Page 39908]]

hospital's FTE cap may be considered when calculating the hospital's 
rural track FTE limitation and count. In the scenario the commenter 
outlined above, if the first program year of the rural track program 
began on July 1, 1993, then the fourth program year would begin on July 
1, 1996, not in 1997. Because 15 FTEs were already included in the 
hospital's FTE cap, assuming the urban hospital qualifies to count the 
FTEs, only 3 out of the 18 FTE residents training in the program may be 
considered in determining the hospital's rural track FTE limitation and 
counts (the specific rural FTE limitation and count are dependent upon 
which scenario the hospital's program fits under Sec. 413.86(g)(11)).
    We do not believe it is necessary to revise this policy for 
hospitals whose only GME program is the rural track program that was in 
existence prior to 1996, as the commenter suggested. Hospitals that had 
rural track programs in existence in 1996 were able to count those 
residents training at the urban hospital at that time as part of their 
initial FTE caps. Our existing policy on rural tracks at 
Sec. 413.86(g)(11) provides additional assistance to these hospitals by 
allowing them to count separately in their rural track FTE limitations, 
FTE residents not included in the FTE cap but participating in a rural 
track.
    Accordingly, we are adopting the provisions in the August 1, 2000 
interim final rule with comment period implementing section 407(c) of 
Public Law 106-113 as final.
    In addition, we are making a technical correction. The regulations 
at Sec. 413.86(g)(6) currently state, ``If a hospital established a new 
medical residency training program as defined in paragraph (g)(9) of 
this section * * *.'' When we revised the regulations at 
Sec. 413.86(g)(9) to redesignate the paragraph as Sec. 413.86(g)(12) in 
the August 1, interim final rule with comment period, we inadvertently 
did not make a corresponding revision at Sec. 413.86(g)(6). Therefore, 
we are revising Sec. 413.86(g)(6) to read ``If a hospital established a 
new medical residency training program as defined in paragraph (g)(12) 
of this section * * *'' We are making the same revision to the 
regulations for IME at Sec. 412.105(f)(vii).
d. Not Counting Against Numerical Limitation Certain Residents 
Transferred from a Department of Veterans AffairsHospital's Residency 
Program That Loses Accreditation(Section 407(d) of Public Law 106-113 
and new 42 CFR 412.105(f)(1)(xii) and 413.86(g)(10))
    Section 407(d) of Public Law 106-113 addressed the situation where 
residents were training in a residency training program at a Veterans 
Affairs (VA) hospital and then were transferred on or after January 1, 
1997, and before July 31, 1998, to a non-VA hospital because the 
program in which the residents were training would lose its 
accreditation by the ACGME if the residents continued to train at the 
VA hospital. In this situation, the non-VA hospital may receive a 
temporary adjustment to its FTE cap to reflect those residents who were 
transferred to the non-VA hospital for the duration that those 
transferred residents were training at the non-VA hospital. In the 
August 1, 2000 interim final rule with comment period, we specified 
that, in order to receive this adjustment, the non-VA hospital must 
submit a request to its fiscal intermediary for a temporary adjustment 
to its FTE cap, document that the hospital is eligible for this 
temporary adjustment by identifying the residents who have come from 
the VA hospital, and specify the length of time the adjustment is 
needed.
    We noted that section 407(d) of Public Law 106-113 only refers to 
programs that would lose their accreditation by the ACGME. This 
provision does not apply to accreditation by the American Osteopathy 
Association (AOA), the American Podiatry Association (APA), or the 
American Dental Association (ADA).
    Under section 407(d)(3) of Public Law 106-113, this policy is 
effective as if included in the enactment of Public Law 105-33, that 
is, for direct GME, with cost reporting periods beginning on or after 
October 1, 1997, and for IME, discharges occurring on or after October 
1, 1997. If a hospital is owed payments as a result of this provision, 
payments must be made immediately.
    We added Secs. 412.105(f)(1)(xii) and 413.86(g)(10) to incorporate 
the provisions of section 407(d) of Public Law 106-113.
    We did not receive any comments on this provision and are adopting 
it as final.
e. Initial Residency Period for Child Neurology Residency Programs 
(Section 312 of Public Law 106-113 and 42 CFR 413.86(g)(1))
    Generally, section 1886(h)(5)(F) of the Act defines the term 
``initial residency period'' to mean the ``period of board 
eligibility.'' The period of board eligibility is defined in section 
1886(h)(5)(G) of the Act as the period recognized by ACGME as specified 
in the Graduate Medical Education Directory which is published by the 
American Medical Association. The initial residency period limitation 
was designed to limit full Medicare payment for direct GME to the time 
required to train in a single specialty. Therefore, the initial 
residency period is determined based on the minimum time required for a 
resident to become board eligible in a specialty and the published 
periods included in the Graduate Medical Education Directory. During 
the initial residency period, the residents are weighted at 1.0 FTE for 
purposes of Medicare payment. Residents seeking additional specialty or 
subspecialty training are weighted at 0.5 FTE.
    In order to become board eligible in child neurology, residents 
must complete training in more than one specialty. Thus, for example, 
before the effective date of section 312 of Public Law 106-113, if a 
resident enrolled in a child neurology residency program by first 
completing 2 years of training in pediatrics (which is associated with 
a 3-year initial residency period), followed by 3 years of training in 
child neurology, the resident would be limited by the initial residency 
period of pediatrics. Section 312 of Public Law 106-113 amended section 
1886(h)(5) of the Act by adding at the end a clause (v) which states 
that ``in the case of a resident enrolled in a child neurology 
residency training program, the period of board eligibility and the 
initial residency period shall be the period of board eligibility for 
pediatrics plus 2 years.'' (The initial residency period for pediatrics 
is currently 3 years). The policy under section 312(b) of Public Law 
106-113 applies to future child neurology residents and to child 
neurology residents who have already begun their training (for whom an 
initial residency period was already established). However, it does not 
apply to residents who have completed their child neurology training 
before July 1, 2000.
    In the August 1, 2000 interim final rule with comment period, we 
revised Sec. 413.86(g)(1) to reflect that, effective on or after July 
1, 2000, for residency programs that began before, on, or after

[[Page 39909]]

November 29, 1999, the period of board eligibility and the initial 
residency period for child neurology is now the period of board 
eligibility for pediatrics plus 2 years. We noted that the initial 
residency period is the same for all child neurology residents, 
regardless of whether or not the resident completes the first year of 
training in pediatrics or neurology.
    We did not receive any comments on this provision and are adopting 
it as final.
f. Technical Amendment
    In the August 1, 2000 interim final rule with comment period, we 
indicated that it had come to our attention that the first sentence of 
the then existing Sec. 413.86(g)(1) contains a technical error. The 
first sentence of this paragraph reads ``For purposes of this section, 
an initial residency period is the number of years necessary to satisfy 
the minimum requirements for certification in a specialty or 
subspecialty, plus one year.'' This section of the regulation was 
revised as a result of section 13563(b) of Public Law 103-66, and was 
effective only until June 30, 1995. Generally, effective July 1, 1995, 
an initial residency period is defined as the minimum number of years 
required for board eligibility. Therefore, we revised the first 
sentence of paragraph (g)(1) of Sec. 413.86 accordingly. The remainder 
of paragraph (g)(1) of Sec. 413.86 was unchanged.
    We did not receive any comments on this provision and are adopting 
it as final.

I. Additional Payment to Hospitals that Operate Approved Nursing and 
Allied Health Education Programs

    Under sections 1861(v) and 1886(a) of the Act, hospitals that 
operate approved nursing or allied health education programs may be 
eligible for the reimbursement of their reasonable costs of operating 
such programs. Section 1886(h) of the Act establishes the methodology 
for determining payments to hospitals for the direct costs of GME 
programs. Section 1886(h) of the Act, as implemented in regulations at 
42 CFR 413.86, specifies that Medicare payments for direct costs of GME 
are based on a prospectively determined per resident amount (PRA). The 
PRA is multiplied by the number of full-time equivalent residents 
working in all areas of the hospital complex (and nonhospital sites, 
where applicable), and the product is then multiplied by the hospital's 
Medicare share of total inpatient days to determine Medicare's direct 
GME payment.
    Section 1886(h)(3)(D) of the Act, as added by section 4624 of 
Public Law 105-33, provides a 5-year phase-in of payments to teaching 
hospitals for direct costs of GME associated with services to 
Medicare+Choice (managed care) enrollees for portions of cost reporting 
periods occurring on or after January 1, 1998. The amount of payment 
for direct GME is calculated by (1) multiplying the aggregate approved 
amount (that is, the product of the PRA and the number of FTE residents 
working in all areas of the hospital (and nonhospital sites, if 
applicable)), by the ratio of the number of inpatient bed days that are 
attributable to Medicare+Choice enrollees to total inpatient bed days, 
and (2) multiplying the result by an applicable percentage.
    The applicable percentages are 20 percent for portions of cost 
reporting periods occurring in calendar year 1998, 40 percent in 
calendar year 1999, 60 percent in calendar year 2000, 80 percent in 
calendar year 2001, and 100 percent in calendar year 2002 and 
subsequent years. (Section 1886(d)(11) of the Act, as added by section 
4622 of Public Law 105-33, provides a 5-year phase-in of payments to 
teaching hospitals for IME associated with services to Medicare+Choice 
enrollees for portions of cost reporting periods occurring on or after 
January 1, 1998, as well. However, the Medicare+Choice IME payments are 
irrelevant for the purposes of this section of the interim final rule 
with comment period, because although section 541 of Public Law 106-113 
affects the payments for Medicare+Choice direct GME, it in no way 
affects the payments for Medicare+Choice IME.)
1. Provisions of the August 1, 2000 Interim Final Rule with Comment 
Period (Section 541 of Public Law 106-113 and 42 CFR 413.86(d) and 
413.87)
    Section 541 of Public Law 106-113 further amended section 1886 of 
the Act by adding subsection (l) and amending section 1886(h)(3)(D) to 
provide for additional payments to hospitals for nursing and allied 
health education programs associated with services to Medicare+Choice 
enrollees. Hospitals that operate approved nursing or allied health 
education programs, as defined under the regulations at 42 CFR 413.85, 
and receive Medicare reasonable cost reimbursement for these programs, 
would receive additional payments. This provision is effective for 
portions of cost reporting periods occurring in a calendar year, 
beginning with calendar year 2000.
    Section 1886(l) of the Act, as added by section 541 of Public Law 
106-113, specifies the methodology to be used to calculate these 
additional payments and places a limitation, that is, $60 million, on 
the total amount that is projected to be expended in any calendar year. 
We refer to the total amount of $60 million or less as the payment 
``pool.'' We emphasize that we use the term ``pool'' solely for ease of 
reference; the term reflects an estimated dollar figure, a number that 
is plugged into a formula to calculate the amount of additional 
payments. The term ``pool'' does not refer to a discrete fund of money 
that is set aside in order to make the additional payments (thus, for 
example, if the estimated ``pool'' is $50 million, we use the number 
$50 million to calculate the amount of additional payments, but this 
does not mean that we set aside $50 million in a separate fund from 
which we make the additional payments). The total amount of additional 
payments is based on the ratio of estimated total direct GME payments 
for Medicare+Choice enrollees to estimated total Medicare direct GME 
payments, multiplied by the total Medicare nursing and allied health 
education payments. Under section 541 of Public Law 106-113, a hospital 
would receive its share of these additional payments in proportion to 
the amount of Medicare nursing and allied health education payments 
received in the cost reporting period that ended in the fiscal year 
that is 2 years prior to the current calendar year, to the total amount 
of nursing and allied health payments made to all hospitals in that 
cost reporting period. Section 541(b) of Public Law 106-113 amended 
section 1886(h)(3) of the Act to provide that direct GME payments for 
Medicare+Choice utilization will be reduced to account for the 
additional payments that are made for nursing and allied health 
education programs under the provisions of section 1886(l) of the Act.
    In the August 1, 2000 interim final rule with comment period, we 
implemented section 541 by establishing regulations at 42 CFR 413.87 to 
incorporate the provisions of section 1886(l) of the Act. We specified 
the rules for a hospital's eligibility to receive the additional 
payment under section 1886(l), the requirements for determining the 
additional payment to each eligible hospital, and the methodologies for 
calculating each additional payment and for calculating the payment 
``pool.'' The preamble language regarding Sec. 413.87 can be found in 
the August 1, 2000 interim final rule with comment period (65 FR 47036 
through 47039).
    We also made a conforming change to Secs. 413.86(d)(4) through 
(d)(6) to account

[[Page 39910]]

for the revised methodology in determining a hospital's Medicare+Choice 
direct GME payments.
2. Provisions of the June 13, 2001 Interim Final Rule with Comment 
Period
a. Additional Payment to Hospitals That Operate Approved Nursing and 
Allied Health Programs (Section 512 of Public Law 106-554 and 42 CFR 
413.87)
    Public Law 106-554 further amended section 1886(l)(2)(C) of the 
Act. Specifically, section 512 of Public Law 106-554 changed the 
formula for determining the additional amounts to be paid to hospitals 
for Medicare+Choice nursing and allied health costs. Under Public Law 
106-113, as described above, the additional payment amount was 
determined based on the proportion of each individual hospital's 
nursing and allied health education payments to total nursing and 
allied health education payments made across all hospitals. This 
formula does not account for a hospital's specific Medicare+Choice 
utilization. Section 512 of Public Law 106-554 revised this payment 
formula to specifically account for each hospital's Medicare+Choice 
utilization. Accordingly, we made conforming changes at Sec. 413.87 to 
reflect this change. The changes are effective for portions of cost 
reporting periods occurring on or after January 1, 2001. We refer the 
reader to the preamble of the June 13 interim final rule with comment 
period for a detailed description of the revised methodology for 
calculating the additional payments (66 FR 32178).
    We revised Sec. 413.87 to incorporate the provisions of section 512 
of Public Law 106-554.
b. Technical Amendment
    In the June 13, 2001 interim final rule with comment period, we 
indicated that it had come to our attention that the regulations at 
Sec. 413.86(d)(4) and Sec. 413.87(d) contained errors. The regulations 
at Sec. 413.86(d)(4) had read, ``Effective for cost reporting periods 
beginning on or after January 1, 2000, the product derived from step 
three is reduced in accordance with the provisions of Sec. 413.87(f).'' 
Consistent with the statutory effective date and to clarify the intent 
of the reference to Sec. 413.87(f), we revised Sec. 413.86(d)(4) to 
state that, ``Effective for portions of cost reporting periods 
occurring on or after January 1, 2000, the product derived from step 
three is reduced by a percentage equal to the ratio of the 
Medicare+Choice nursing and allied health payment ``pool'' for the 
current calendar year as described at Sec. 413.87(f), to the projected 
total Medicare+Choice direct GME payments made to all hospitals for the 
current calendar year.'' We also made a conforming change to 
Sec. 413.87(d), which had read, ``Subject to the provisions of 
paragraph (f) of this section * * *.'' Instead, we revised this 
language to state, ``Subject to the provisions of Sec. 413.86(d)(4) * * 
*.''

J. Payment for Bad Debts (Section 541 of Public Law 106-554 and 42 CFR 
413.80)

    Section 4451 of Public Law 105-33 required that allowable bad debt 
reimbursement for hospitals be reduced by 25 percent for cost reporting 
periods beginning during FY 1998, by 40 percent for cost reporting 
periods beginning during FY 1999, and by 45 percent for cost reporting 
periods beginning during a subsequent fiscal year.
    In the June 13, 2001 interim final rule with comment period (66 FR 
32183), we implemented section 541 of Public Law 106-554. Section 541 
amended section 1861(v)(1)(T) of the Act, thereby modifying the 
reduction in payment for Medicare beneficiary bad debt for hospitals 
made by section 4451 of Public Law 105-33. Specifically, this provision 
reduced the amount of bad debts otherwise treated as allowable 
reductions in revenue, attributable to the deductibles and coinsurance 
amounts, by 30 percent for cost reporting periods beginning during FY 
2001 and later. Therefore, for cost reporting periods beginning during 
the year 2001 and later, hospital bad debt amounts otherwise allowable 
will be reimbursed at 70 percent of the total allowable amount. In the 
June 13 interim final rule with comment period, we revised Sec. 413.80 
to implement this change.
    We did not receive any comments on this provision and, therefore, 
are adopting the proposed revision to Sec. 413.80 as final.

V. Changes to the Prospective Payment System for Capital-Related 
Costs

A. End of the Transition Period

    Federal fiscal year (FY) 2001 is the last year of the 10-year 
transition period established to phase in the prospective payment 
system for hospital capital-related costs. For the readers' benefit, we 
are providing a summary of the statutory basis for the system, the 
development and evolution of the system, the methodology used to 
determine capital-related payments to hospitals, and the policy for 
providing exceptions payments during the transition period.
    Section 1886(g) of the Act requires the Secretary to pay for the 
capital-related costs of inpatient hospital services ``in accordance 
with a prospective payment system established by the Secretary.'' Under 
the statute, the Secretary has broad authority in establishing and 
implementing the capital prospective payment system. We initially 
implemented the capital prospective payment system in the August 30, 
1991 final rule (56 FR 43409), in which we established a 10-year 
transition period to change the payment methodology for Medicare 
inpatient capital-related costs from a reasonable cost-based 
methodology to a prospective methodology (based fully on the Federal 
rate).
    The 10-year transition period established to phase-in the 
prospective payment system for capital-related costs is effective for 
cost reporting periods beginning on or after October 1, 1991 (FY 1992) 
and before October 1, 2001 (FY 2002). Beginning in FY 2001, the last 
year of the 10-year transition period for the prospective payment 
system for hospital capital-related costs, capital prospective payment 
system payments are based solely on the Federal rate for the vast 
majority of hospitals. Since FY 2001 is the final year of the capital 
transition period, we will no longer determine a hospital-specific rate 
for FY 2002 in section III. of the Addendum of this final rule. For 
cost reporting periods beginning on or after October 1, 2001, payment 
for capital-related costs for all hospitals, except those defined as 
new hospitals under Sec. 412.324(b), will be determined based solely on 
the capital standard Federal rate.
    Generally, during the transition period, inpatient capital-related 
costs are paid on a per discharge basis, and the amount of payment 
depends on the relationship between the hospital-specific rate and the 
Federal rate during the hospital's base year. A hospital with a base 
year hospital-specific rate lower than the Federal rate is paid under 
the fully prospective payment methodology during the transition period. 
This method is based on a dynamic blend percentage of the hospital's 
hospital-specific rate and the applicable Federal rate for each year 
during the transition period. A hospital with a base period hospital-
specific rate greater than the Federal rate is paid under the hold-
harmless payment methodology during the transition period.
    During the transition period, a hospital paid under the hold-
harmless payment methodology receives the higher of (1) a blended 
payment of 85 percent of reasonable cost for old capital plus an amount 
for new capital based on

[[Page 39911]]

a portion of the Federal rate; or (2) a payment based on 100 percent of 
the adjusted Federal rate. The amount recognized as old capital is 
generally limited to the allowable Medicare capital-related costs that 
were in use for patient care as of December 31, 1990. Under limited 
circumstances, capital-related costs for assets obligated as of 
December 31, 1990, but put in use for patient care after December 31, 
1990, also may be recognized as old capital if certain conditions were 
met. These costs are known as obligated capital costs. New capital 
costs are generally defined as allowable Medicare capital-related costs 
for assets put in use for patient care after December 31, 1990.
    Hospitals that are defined as ``new'' for the purposes of capital 
payments during the transition period (see Sec. 412.300(b)) will 
continue to be paid according to the applicable payment methodology 
outlined in Sec. 412.324. During the transition period, new hospitals 
are exempt from the prospective payment system for capital-related 
costs for their first 2 years of operation and are paid 85 percent of 
their reasonable capital-related costs during that period. The 
hospital's first 12-month cost reporting period (or combination of cost 
reporting periods covering at least 12 months), beginning at least 1 
year after the hospital accepts its first patient, serves as the 
hospital's base period. Those base year costs qualify as old capital 
and are used to establish its hospital-specific rate used to determine 
its payment methodology under the capital prospective payment system. 
Effective with the third year of operation and through the remainder of 
the transition period, the hospital will be paid under either the fully 
prospective methodology or the hold-harmless methodology. If the fully 
prospective methodology is applicable, the hospital is paid using the 
appropriate transition blend of its hospital-specific rate and the 
Federal rate for that fiscal year until the conclusion of the 
transition period, at which time the hospital will be paid based on 100 
percent of the Federal rate. If the hold-harmless methodology is 
applicable, the hospital will receive hold-harmless payment for assets 
in use during the base period for 8 years, which may extend beyond the 
10-year transition period.
    The basic methodology for determining capital prospective payments 
based on the Federal rate is set forth in Sec. 412.312. For the purpose 
of calculating payments for each discharge, the standard Federal rate 
is adjusted as follows:

(Standard Federal Rate)  x  (DRG Weight)  x  (GAF)  x  (Large Urban 
Add-on, if applicable)  x  (COLA Adjustment for Hospitals Located in 
Alaska and Hawaii)  x  (1 + DSH Adjustment Factor + IME Adjustment 
Factor)

    Hospitals may also receive outlier payments for those cases that 
qualify under the thresholds established for each fiscal year. Section 
412.312(c) provides for a single set of thresholds to identify outlier 
cases for both inpatient operating and inpatient capital-related 
payments.
    In accordance with section 1886(d)(9)(A) of the Act, under the 
prospective payment system for inpatient operating costs, hospitals 
located in Puerto Rico are paid for operating costs under a special 
payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a 
blended rate that consisted of 75 percent of the applicable 
standardized amount specific to Puerto Rico hospitals and 25 percent of 
the applicable national average standardized amount. However, effective 
October 1, 1997, under amendments to the Act enacted by section 4406 of 
Public Law 105-33, operating payments to hospitals in Puerto Rico are 
based on a blend of 50 percent of the applicable standardized amount 
specific to Puerto Rico hospitals and 50 percent of the applicable 
national average standardized amount. In conjunction with this change 
to the operating blend percentage, effective with discharges on or 
after October 1, 1997, we compute capital payments to hospitals in 
Puerto Rico based on a blend of 50 percent of the Puerto Rico rate and 
50 percent of the Federal rate as specified in the regulations at 
Sec. 412.374. For capital-related costs, we compute a separate payment 
rate specific to Puerto Rico hospitals using the same methodology used 
to compute the national Federal rate for capital-related costs.
    In the August 30, 1991 final rule (56 FR 43409), we established a 
capital exceptions policy, which provided for exceptions payments 
during the transition period (Sec. 412.348). Section 412.348 provides 
that during the transition period, a hospital may receive additional 
payment under the exceptions process when its regular payments are less 
than a minimum percentage, established by class of hospital, of the 
hospital's reasonable capital-related costs. The amount of the 
exceptions payment is the difference between the hospital's minimum 
payment level and the payments the hospital would have received under 
the capital prospective payment system in the absence of an exceptions 
payment. The comparison is made on a cumulative basis for all cost 
reporting periods during which the hospital has been subject to the 
capital prospective payment transition rules. The minimum payment 
percentages throughout the transition period for regular capital 
exceptions payments by class of hospitals are:
     For sole community hospitals, 90 percent;
     For urban hospitals with at least 100 beds that have a 
disproportionate share patient percentage of at least 20.2 percent or 
that received more than 30 percent of their net inpatient care revenues 
from State or local governments for indigent care, 80 percent;
     For all other hospitals, 70 percent of the hospital's 
reasonable inpatient capital-related costs.
    The provision for ``regular'' exceptions payments expires at the 
end of the transition period, that is, for cost reporting periods 
beginning after September 30, 2001. Capital prospective payment system 
payments are no longer adjusted to reflect regular exceptions payments 
at Sec. 412.348 after that date. Accordingly, for cost reporting 
periods beginning on or after October 1, 2001, all hospitals other than 
those defined as ``new'' under Sec. 412.324(b) will receive only the 
per discharge payment based on the Federal rate for capital costs (plus 
any applicable DSH or IME and outlier adjustments) unless a hospital 
qualifies for a special exceptions payment under Sec. 412.348(g).

B. Special Exceptions Process

    In the August 30, 1991 final rule (56 FR 43409), we established a 
capital exceptions policy at Sec. 412.348, which provided for regular 
exception payments during the transition period. In the September 1, 
1994 final rule (59 FR 45385), we added the special exceptions process, 
describing it as ``* * * narrowly defined, focusing on a small group of 
hospitals who found themselves in a disadvantaged position. The target 
hospitals were those who had an immediate and imperative need to begin 
major renovations or replacements just after the beginning of the 
capital prospective payment system. These hospitals would not be 
eligible for protection under the old capital and obligated capital 
provisions, and would not have been allowed any time to accrue excess 
capital prospective payments to fund these projects.''
    Under the special exceptions provisions at Sec. 412.348(g), an 
additional payment may be made through the 10th year beyond the end of 
the capital

[[Page 39912]]

prospective payment system transition period for eligible hospitals 
that meet (1) a project need requirement as described at 
Sec. 412.348(g)(2), which, in the case of certain urban hospitals, 
includes an excess capacity test; and (2) a project size requirement as 
described at Sec. 412.348(g)(5). Eligible hospitals include sole 
community hospitals, urban hospitals with at least 100 beds that have a 
disproportionate share patient percentage of at least 20.2 percent, and 
hospitals with a combined Medicare and Medicaid inpatient utilization 
of at least 70 percent.
    When we established the special exceptions process, we selected the 
hospital's cost reporting period beginning before October 1, 2001, as 
the project completion date in order to limit cost-based exceptions 
payments to a period of not more than 10 years beyond the end of the 
10-year transition to the fully Federal capital prospective payment 
system. Therefore, hospitals are eligible to receive special exceptions 
payments for the 10 years after the cost reporting year in which they 
complete their project. Generally, if a project is completed in the 
hospital cost reporting period ending September 29, 2002, exceptions 
payments would continue through September 29, 2012. In addition, we 
believe that, for projects completed after the deadline, hospitals 
would have had the opportunity to reserve their prior years' capital 
prospective payment system payments for financing projects. We note 
that the August 1, 2000 final rule (65 FR 47095) incorrectly stated 
that special exceptions payments could extend through September 30, 
2011; the date should have been September 29, 2012.
    For each cost reporting period, the amount of the special 
exceptions payment is determined by comparing the cumulative payments 
made to the hospital under the capital payment system to the cumulative 
minimum payment levels applicable to the hospital for each cost 
reporting period subject to the prospective payment system. This 
comparison is offset or reduced by (1) any amount by which the 
hospital's cumulative payments exceed its cumulative minimum payments 
under the regular exceptions process for all cost reporting periods 
during which the hospital has been subject to the capital prospective 
payment system; and (2) any amount by which the hospital's current year 
Medicare inpatient operating and capital prospective payment system 
payments (excluding 75 percent of its operating DSH payments) exceed 
its Medicare inpatient operating and capital costs (or its Medicare 
inpatient margin). During the capital prospective payment system 
transition period, the minimum payment level under the regular 
exceptions process varied by class of hospital as set forth in 
Sec. 412.348(c) and described in section V.A. of this preamble. After 
the transition period and for the duration of the special exceptions 
provision, the minimum payment level is 70 percent as set forth in 
Sec. 412.348(g)(6).
    As we indicated in the July 30, 1999 final rule (64 FR 41526), we 
have little information about the number of hospitals that may qualify 
for special exceptions payments or the projected dollar amount of 
special exception payments, because no hospitals are currently being 
paid under the special exceptions process. Until FY 2002, the special 
exceptions provision pays either the same as the regular exceptions 
process or less for high DSH and sole community hospitals. In 
accordance with Sec. 412.348(g)(7), a qualifying hospital may receive 
additional payments for up to 10 years from the year in which it 
completes a project that meets the project need and project size 
requirements of the special exception provision in Secs. 412.348(g)(2) 
through (g)(5). Because a qualifying project under the special 
exceptions provision at Sec. 412.348(g) must be completed (put into use 
for patient care) by the end of the hospital's last cost reporting 
period beginning before the end of the transition period (September 30, 
2001), a hospital may receive special exception payments for 10 years 
through September 30, 2012. For example, an eligible hospital that 
completes a qualifying project in October 1993 (FY 1994) will be 
eligible to receive special exception payments up through FY 2003 
(September 30, 2003).
    In order to assist our fiscal intermediaries in determining the end 
of the 10-year period in which an eligible hospital will no longer be 
entitled to receive special exception payments, in the May 4, 2001 
proposed rule, we proposed to add a new Sec. 412.348(g)(9) to require 
that hospitals eligible for special exception payments under 
Sec. 412.348(g) submit documentation to the intermediary indicating the 
completion date of their project (the date the project was put in use 
for patient care) that meets the project need and project size 
requirements outlined in Secs. 412.348(g)(2) through (g)(5). We 
proposed that, in order for an eligible hospital to receive special 
exception payments, this documentation would have to be submitted in 
writing to the intermediary by the later of October 1, 2001, or within 
3 months of the end of the hospital's last cost reporting period 
beginning before October 1, 2001, during which a qualifying project was 
completed. For example, if a hospital completed a qualifying project in 
March 1995, it would be required to submit documentation to the 
intermediary by October 1, 2001. If a hospital with a 12-month cost 
reporting period beginning on July 1 completed a qualifying project in 
November 2001, it would be required to submit documentation to the 
intermediary no later than September 30, 2002, which is 3 months after 
the end of its 12-month cost reporting period that began on July 1, 
2001.
    We did not receive any comments on our proposed revision to 
Sec. 412.348 to add paragraph (g)(9). Accordingly, we are adopting the 
proposed revision as final without change.

C. Exceptions Minimum Payment Level

    Section 412.348(h) limits the estimated aggregate amount of 
exceptions payments under both the regular exceptions and special 
exceptions process to no more than 10 percent of the total estimated 
capital prospective payment system payments in a given fiscal year. 
Consistent with the requirements for regular exceptions at 
Sec. 412.348(c), in the May 4, 2001 proposed rule, we proposed that if 
we estimate that special exception payments would exceed 10 percent of 
total capital prospective payment system payments for a given fiscal 
year, we will adjust the minimum payment level of 70 percent by one 
percentage point increments until the estimated payments are within the 
10-percent limit. For example, we could set the minimum payment level 
at 69 percent to ensure that estimated aggregate special exceptions 
payments do not exceed 10 percent of estimated total capital 
prospective payment system payments. If the estimate of aggregate 
special exceptions payments were still projected to exceed 10 percent 
of total capital prospective payment system payments, we would continue 
reducing the minimum payment level by one percentage point increments 
until the requirements in Sec. 412.348(h) were satisfied. We proposed 
to revise Sec. 412.348(g)(6) accordingly to reflect this policy.
    We received no comments on this proposed change. Thus, we are 
revising Sec. 412.348(g)(6) accordingly.

D. Exceptions Adjustment Factor

    Section 412.308(c)(3) requires that the standard capital Federal 
rate be reduced by an adjustment factor equal to the estimated 
proportion of additional payments for both regular exceptions and 
special exceptions under Sec. 412.348

[[Page 39913]]

relative to total capital prospective payment system payments. In 
estimating the proportion of regular exceptions payments to total 
capital prospective payment system payments during the transition 
period, we used the model originally developed for determining budget 
neutrality (described in Appendix B of this final rule) to determine 
the exception adjustment factor, which was applied to both the Federal 
and hospital-specific rates. In the May 4, 2001 proposed rule, we 
described our proposed methodology for determining the special 
exceptions adjustment used in establishing the Federal capital rate as 
follows:
    Under the special exceptions provision specified at 
Sec. 412.348(g)(1), eligible hospitals include SCHs, urban hospitals 
with at least 100 beds that have a disproportionate share patient 
percentage of at least 20.2 percent or qualify for DSH payments under 
Sec. 412.106(c)(2), and hospitals with a combined Medicare and Medicaid 
inpatient utilization of at least 70 percent. An eligible hospital may 
receive special exception payments if it meets (1) a project need 
requirement as described at Sec. 412.348(g)(2), which, in the case of 
certain urban hospitals, includes an excess capacity test; (2) an age 
of assets test as described at Sec. 412.348(g)(3); and (3) a project 
size requirement as described at Sec. 412.348(g)(5).
    In order to determine the estimated proportion of special 
exceptions payments to total capital payments, we attempted to identify 
the universe of eligible hospitals that may potentially qualify for 
special exception payments. First, we identified hospitals that met the 
eligibility requirements at Sec. 412.348(g)(1). Then we determined each 
hospital's average fixed asset age in the earliest available cost 
report starting in FY 1992 and later. For each of those hospitals, we 
calculated the average fixed asset age by dividing the accumulated 
depreciation by the current year's depreciation. In accordance with 
Sec. 412.348(g)(3), a hospital must have an average age of buildings 
and fixed assets above the 75th percentile of all hospitals in the 
first year of capital prospective payment system. In the September 1, 
1994 final rule (59 FR 45385), we stated that, based on the June 1994 
update of the cost report files in HCRIS, the 75th percentile for 
buildings and fixed assets for FY 1992 was 16.4 years. However, we 
noted that we would make a final determination of that value on the 
basis of more complete cost report information at a later date. In the 
August 29, 1997 final rule (62 FR 46012), based on the December 1996 
update of HCRIS and the removal of outliers, we finalized the 75th 
percentile for buildings and fixed assets for FY 1992 as 15.4 years. 
Thus, for the proposed rule, we eliminated any hospitals from the 
potential universe of hospitals that may qualify for special exception 
payments if its average age of fixed assets did not exceed 15.4 years.
    For the hospitals remaining in the potential universe, we proposed 
to estimate the project-size by using the fixed capital acquisitions 
shown on Worksheet A7 from the following HCRIS cost reports updated 
through December 2000.

------------------------------------------------------------------------
                                                Cost reports periods
                 PPS Year                       beginning  in . . .
------------------------------------------------------------------------
IX.......................................  FY 1992
X........................................  FY 1993
XI.......................................  FY 1994
XII......................................  FY 1995
XIII.....................................  FY 1996
XIV......................................  FY 1997
XV.......................................  FY 1998
XVI......................................  FY 1999
------------------------------------------------------------------------

    Because the project phase-in may overlap 2 cost reporting years, we 
proposed to add together the fixed acquisitions from sequential pairs 
of cost reports to determine project size. Under Sec. 412.348(g)(5), 
the project-size must meet the following requirements: (1) $200 
million; or (2) 100 percent of its operating cost during the first 12-
month cost reporting period beginning on or after October 1, 1991. We 
proposed to calculate the operating costs from the earliest available 
cost report starting in FY 1992 and later by subtracting inpatient 
capital costs from inpatient costs (for all payers). We proposed not to 
subtract the direct medical education costs as those costs are not 
available on every update of the HCRIS minimum data set. If the 
hospital met the project size requirement, we assumed that it also met 
the project need requirements at Sec. 412.348(g)(2) and the excess 
capacity test for urban hospitals at Sec. 412.348(g)(4).
    Because we estimate that so few hospitals will qualify for special 
exceptions, projecting costs, payments, and margins would result in 
high statistical variance. Consequently, we modeled the effects of 
special exceptions using historical data based on hospitals' actual 
cost experiences. If we determined that a hospital may qualify for 
special exceptions, we modeled special exceptions payments from the 
project start date through the last available cost report (FY 1999). 
For purposes of modeling, we used the cost and payment data on the cost 
reports from HCRIS assuming that special exceptions would begin at the 
start of the qualifying project. In other words, when modeling costs 
and payment data we proposed to ignore any regular exception payments 
that these hospitals may otherwise have received as if there had not 
been regular exceptions during the transition period. In projecting an 
eligible hospital's special exception payments, we applied the 70-
percent minimum payment level, the cumulative comparison of current 
year capital prospective payment system payments and costs, and the 
cumulative operating margin offset (excluding 75 percent of operating 
DSH payments).
    Because hospitals may receive regular exceptions payments up 
through the end of their last cost reporting period beginning before 
October 1, 2001, hospitals with cost reporting periods beginning on a 
day other than October 1 will continue to receive regular exception 
payments until the end of their FY 2002 cost reporting period. 
Therefore, these hospitals will only receive special exception payments 
for the remainder of Federal FY 2002. Consequently, the special 
exceptions payments made in FY 2002 will be less than for subsequent 
years since they are only being paid a special exception payment for a 
portion of FY 2002.
    Based on more recent data and HCRIS cost reports updated through 
March 2001, our modeling of special exception payments produced the 
following results:

[[Page 39914]]



----------------------------------------------------------------------------------------------------------------
                                                                                                      Special
                                                                                                   exceptions as
                                                                                                   a fraction of
                                                                                      Special         capital
                                                                     Number of     exceptions as    payments to
                                                                     hospitals     a fraction of   all hospitals
                           Cost report                             eligible for       capital       weighted by
                                                                      special       payments to    portion of FY
                                                                    exceptions     all hospitals  2002 for which
                                                                                                      special
                                                                                                  exceptions are
                                                                                                       paid
----------------------------------------------------------------------------------------------------------------
PPS IX..........................................................  ..............  ..............  ..............
PPS X...........................................................  ..............  ..............  ..............
PPS XI..........................................................               3  ..............  ..............
PPS XII.........................................................               6          0.0001          0.0001
PPS XIII........................................................               7          0.0001          0.0000
PPS XIV.........................................................              14          0.0002          0.0001
PPX XV..........................................................              17          0.0009          0.0002
PPS XVI.........................................................              23          0.0009          0.0007
----------------------------------------------------------------------------------------------------------------

    Currently, the PPS XVI cost reports in HCRIS are incomplete because 
there is a 2-year lag time between the end of a hospital's cost 
reporting period and the submission and processing of the cost reports 
for HCRIS. In particular, we have not received all the cost reports for 
hospitals whose cost reporting periods begin in July. We expect that 
more hospitals may qualify for special exceptions once data from later 
HCRIS updates are available. In addition, hospitals still have two more 
cost reporting periods (PPS XVII and PPS XVIII) to complete their 
projects in order to be eligible for special exceptions.
    In the May 4, 2001 proposed rule (66 FR 22705), we estimated that 
about 30 additional hospitals could qualify for special exceptions. 
Based on more recent data, we still estimate that about 30 additional 
hospitals could qualify for special exceptions. Thus, we project that 
special exception payments as a fraction of capital payments to all 
hospitals is approximately 0.0025. However, after weighting this amount 
to account for the FY 2002 phase-in of special exception payments, we 
project that this factor is approximately 0.0012. These projections 
have not changed since the publication of the May 4, 2001 proposed rule 
(66 FR 22706). We received no comments on our proposed methodology for 
determining the special exceptions adjustment used in establishing the 
capital Federal rate. Because special exceptions are budget neutral, we 
will offset the Federal capital rate by 0.12 percent for special 
exceptions for FY 2002. Therefore, the final special exceptions 
adjustment factor is equal to 0.9988 (1-0.0012) to account for special 
exception payments in FY 2002.

E. Provisions Relating to Capital Prospective Payments in the June 13, 
2001 Interim Final Rule With Comment Period

    In the June 13, 2001 interim final rule with comment period, we 
implemented section 301(b) of Public Law 106-554 (66 FR 32176). Section 
301(b) provides for a special rule for payment for the operating 
standardized amounts for hospitals other than SCHs for FY 2001. For 
discharges occurring on or after April 1, 2001, and before October 1, 
2001, the update to the operating standardized amounts for hospitals 
other than SCHs is equal to the market basket percentage increase plus 
1.1 percentage points. This provision amends the prior statutory 1.1 
percent reduction to the update to the FY 2001 operating standardized 
amounts for hospitals other than SCHs as provided by section 4401(a)(1) 
of Public Law 105-33 and 406 of Public Law 106-113.
    Section 1886(d)(3)(B) of the Act directs the Secretary to adjust 
the inpatient operating national standardized amounts to account for 
the estimated proportion of operating DRG payments made to payments in 
outlier cases. Accordingly, as a result of this change to the update to 
the operating standardized amounts for discharges occurring on or after 
April 1, 2001 and before October 1, 2001, we revised the fixed-loss 
outlier threshold. The regulations at Sec. 412.312(c) establish a 
unified outlier methodology for inpatient operating and inpatient 
capital-related costs, which utilizes a single set of thresholds to 
identify outlier cases for both inpatient operating and inpatient 
capital prospective payment system payments.
    Because operating DRG payments increased as a result of 
implementing section 301 of Public Law 106-554, the fixed-loss outlier 
threshold decreased, which resulted in an increase in estimated outlier 
payments. Thus, the capital national outlier adjustment factor was 
revised. Since the revision to the fixed-loss outlier threshold also 
affected total capital payments, the exceptions adjustment factor was 
also revised in order to maintain budget neutrality. The exceptions 
adjustment factor is determined based on an estimate of the ratio of 
exception payments to total capital payments. The GAF/DRG budget 
neutrality factor was also revised. We discuss the impact of changes to 
the rates and payments under the capital prospective payment system 
that result from implementation of section 301 of Public Law 106-554 in 
further detail in the Addendum of this final rule.
    We did not receive any comments on the revised FY 2001 capital 
Federal rate for discharges occurring on or after April 1, 2001 and 
before October 1, 2001 as a result of implementing section 301(b) of 
Public Law 106-554.

VI. Changes for Hospitals and Hospital Units Excluded From the 
Prospective Payment System

A. Limits on and Adjustments to the Target Amounts for Excluded 
Hospitals and Units (Secs. 413.40(b)(4) and (g))

1. Updated Caps for Existing Hospitals and Units
    Section 1886(b)(3) of the Act (as amended by section 4414 of Public 
Law 105-33) established caps on the target amounts for certain existing 
hospitals and units excluded from the prospective payment system for 
cost reporting periods beginning on or after October 1, 1997 through 
September 30, 2002. The caps on the target amounts apply to the 
following three classes of excluded hospitals: psychiatric hospitals 
and units, rehabilitation hospitals and units, and long-term care 
hospitals.
    In addition, section 4416 of Public Law 105-33 limited payments for

[[Page 39915]]

psychiatric hospitals and units, rehabilitation hospitals and units, 
and long-term care hospitals that first received payments on or after 
October 1, 1997. Payment for these hospitals and units is limited to 
the lesser of the hospital's operating costs per case or 110 percent of 
the national median of target amounts for the same class of hospitals 
for cost reporting periods ending during FY 1996, updated and adjusted 
for differences in area wage levels.
    A discussion of how the caps on the target amounts and the payment 
limitation were calculated can be found in the August 29, 1997 final 
rule with comment period (62 FR 46018); the May 12, 1998 final rule (63 
FR 26344); the July 31, 1998 final rule (63 FR 41000), and the July 30, 
1999 final rule (64 FR 41529). For purposes of calculating the caps for 
existing facilities, the statute required the Secretary to estimate the 
national 75th percentile of the target amounts for each class of 
hospital (psychiatric, rehabilitation, or long-term care) for cost 
reporting periods ending during FY 1996 without adjusting for 
differences in area wage levels. Under section 1886(b)(3)(H)(iii) of 
the Act, the resulting amounts are updated by the market basket 
percentage to the applicable fiscal year.
    Section 121 of Public Law 106-113 amended section 1886(b)(3)(H) of 
the Act to also provide for an appropriate wage adjustment to the caps 
on the target amounts for existing psychiatric hospitals and units, 
rehabilitation hospitals and units, and long-term care hospitals, 
effective for cost reporting periods beginning on or after October 1, 
1999, through September 30, 2002. On August 1, 2000, we published an 
interim final rule with comment period that implemented this provision 
for cost reporting periods beginning on or after October 1, 1999 and 
before October 1, 2000 (65 FR 47026) and a final rule that implemented 
this provision for cost reporting periods beginning on or after October 
1, 2000 (65 FR 47054). This final rule addresses the wage adjustment to 
the caps and payment limitations for cost reporting periods beginning 
on or after October 1, 2001 as proposed in the May 4, 2001 proposed 
rule.
    For purposes of calculating the caps, section 1886(b)(3)(H)(ii) of 
the Act requires the Secretary to first ``estimate the 75th percentile 
of the target amounts for such hospitals within such class for cost 
reporting periods ending during fiscal year 1996.'' Furthermore, 
section 1886(b)(3)(H)(iii), as added by Public Law 106-113, requires 
the Secretary to also provide for existing hospitals ``an appropriate 
adjustment to the labor-related portion of the amount determined under 
such subparagraph to take into account the differences between average 
wage-related costs in the area of the hospital and the national average 
of such costs within the same class of hospital.''
    Consistent with the broad authority conferred on the Secretary by 
section 1886(b)(3)(H)(iii) of the Act to determine the appropriate wage 
adjustment, we account for differences in wage-related costs by 
adjusting the caps to account for the following:
    First, as stated in the May 4 proposed rule, we adjust each 
hospital's target amount to account for area differences in wage-
related costs. For each class of hospitals (psychiatric, 
rehabilitation, and long-term care), we determine the labor-related 
portion of each hospital's FY 1996 target amount by multiplying its 
target amount by the actuarial estimate of the labor-related portion of 
costs (or 0.71553). Similarly, we determine the nonlabor-related 
portion of each hospital's FY 1996 target amount by multiplying its 
target amount by the actuarial estimate of the nonlabor-related portion 
of costs (or 0.28447).
    Next, as we stated in the May 4 proposed rule, we account for wage 
differences among hospitals within each class by dividing the labor-
related portion of each hospital's target amount by the hospital's wage 
index under the hospital inpatient prospective payment system. Within 
each class, each hospital's wage-neutralized target amount was 
calculated by adding the wage-neutralized labor-related portion of its 
target amount and the nonlabor-related portion of its target amount. 
Then, the wage-neutralized target amounts for hospitals within each 
class were arrayed in order to determine the national 75th percentile 
caps on the target amounts for each class.
    Taking into account the national 75th percentile of the target 
amounts for cost reporting periods ending during FY 1996 (wage-
neutralized using the FY 2000 acute care wage index), the wage 
adjustment provided for under Public Law 106-113, and the applicable 
update factor based on the market basket percentage increase for FY 
2001, in the August 1, 2000 final rule (65 FR 47096), we established 
the FY 2001 caps on the target amounts as follows:

------------------------------------------------------------------------
                                                  FY 2001      FY 2001
                                                   labor-     nonlabor-
     Class of  excluded  hospital or unit         related      related
                                                   share        share
------------------------------------------------------------------------
Psychiatric...................................       $8,131       $3,233
Rehabilitation................................       15,164        6,029
Long Term Care................................       29,284       11,642
------------------------------------------------------------------------

    In reviewing our methodology for wage neutralizing the hospital 
specific target amounts, it appears that we incorrectly used the FY 
2000 hospital inpatient prospective payment system wage index published 
in Tables 4A and 4B of the July 30, 1999 final rule (64 FR 41585 
through 41593), which is based on wage data after taking into account 
geographic reclassification under section 1886(d)(8) of the Act. As 
stated in the May 4 proposed rule, we are revising the methodology of 
wage neutralizing the hospital-specific target amounts using pre-
reclassified wage data. We recalculate the limit for new excluded 
hospitals and units, as well as calculate the cap for existing excluded 
hospitals and units, using the pre-reclassification wage index. The 
pre-reclassification wage index is the same wage index used under the 
prospective payment system for skilled nursing facilities (SNFs) and 
was included in Table 7 of the July 30, 1999 SNF final rule (64 FR 
41690). (We note that both SNFs and ambulatory surgical centers use the 
prospective payment system inpatient wage index without regard to the 
prospective payment system reclassification as a proxy for variations 
in local costs.)
    As we stated in the August 1, 2000 final rule, long-term care 
hospitals, rehabilitation hospitals and units, and psychiatric 
hospitals and units that are exempt from the prospective payment system 
are not subject to the prospective payment system hospital 
reclassification system under section 1886(d)(10)(A) of the Act. This 
section establishes the MGCRB for the purpose of evaluating 
applications from short-term, acute care providers. There is no 
equivalent statutory mandate for HCFA to develop an alternative board 
for long-term care hospitals, psychiatric hospitals and units, and 
rehabilitation hospitals and units. In addition, while it would be 
feasible to allow units physically located in prospective payment 
system hospitals that have been reclassified by the MGCRB to use the 
wage index for the area to which that hospital has been reclassified, 
at the present time there is no process in place to make 
reclassification determinations for freestanding excluded providers. 
There are approximately 1,000 freestanding excluded providers. 
Therefore, in the interest of equity, we believe that, in determining a 
hospital's wage-adjusted

[[Page 39916]]

cap on its target amount, it is appropriate for excluded hospitals and 
units to use the wage index associated with the area in which they are 
physically located (MSA or rural area) and the prospective payment 
system reclassification under section 1886(d)(10) of the Act is not 
applicable. This policy is also consistent with the policy for SNFs and 
ambulatory surgical centers that use the acute care, inpatient hospital 
prospective payment system wage index and that does not allow for 
reclassifications since there is no analogous determinations process to 
the MGCRB. The MGCRB only has authority over the prospective payment 
system for acute care hospitals.
    Therefore, based on the broad authority conferred on the Secretary 
by section 1886(b)(3)(H)(iii) of the Act to determine the appropriate 
wage adjustment to the caps, we have determined the labor-related and 
nonlabor-related portions of the caps on the target amounts for FY 2002 
using the methodology outlined above.

------------------------------------------------------------------------
                                                  FY 2001      FY 2001
                                                   labor-     nonlabor-
     Class of  excluded  hospital  or unit        related      related
                                                   share        share
------------------------------------------------------------------------
Psychiatric...................................       $8,429       $3,351
Rehabilitation................................      $15,736       $6,256
Long-Term Care................................      $31,490      $12,519
------------------------------------------------------------------------

    These labor-related and nonlabor-related portions of the caps on 
the target amounts for FY 2002 are based on the current estimate of the 
market basket increase for excluded hospitals and units for FY 2002 of 
3.3 percent and reflect the change in applying the pre-reclassified 
hospital inpatient prospective payment system wage index as discussed 
above. Furthermore, in accordance with section 307(a) of Public Law 
106-554, which amended section 1886(b)(3) of the Act, the labor-related 
and nonlabor-related portions of the cap for long-term care hospitals 
for FY 2002 are increased by 2 percent. A further discussion of this 
provision as it appeared in the June 13, 2001 interim final rule with 
comment period (66 FR 32181) that will implement provisions of Public 
Law 106-554 for FY 2001 and for periods in FY 2001 from April 1, 2001 
through September 30, 2001, appears in section VI.A.4. of this 
preamble.
    Finally, to determine payments described in Sec. 413.40(c), the cap 
on the hospital's target amount per discharge is determined by adding 
the hospital's nonlabor-related portion of the national 75th percentile 
cap to its wage-adjusted, labor-related portion of the national 75th 
percentile cap. A hospital's wage-adjusted, labor-related portion of 
the target amount is calculated by multiplying the labor-related 
portion of the national 75th percentile cap for the hospital's class by 
the hospital's applicable wage index. For FY 2002, a hospital's 
applicable wage index is the pre-reclassified wage index under the 
hospital inpatient prospective payment system (see Sec. 412.63). The 
wage index values are computed based on the same data used to compute 
the FY 2002 wage index values for the hospital inpatient prospective 
payment system without taking into account changes in geographic 
reclassification under the following: Section 1886(d)(8)(B) of the Act 
for certain rural hospitals; section 401 of Public Law 106-113; 
reclassifications based on MGCRB decisions; or the Secretary's 
decisions under sections 1886(d)(8) through (d)(10) of the Act. For 
cost reporting periods beginning on or after October 1, 2001 and before 
October 1, 2002, the pre-reclassified wage index is in Tables 4G and 4H 
of this final rule. A hospital's applicable wage index corresponds to 
the area in which the hospital or unit is physically located (MSA or 
rural area).
2. New Excluded Hospitals and Units
a. Updated Caps (Sec. 413.40(f))
    Section 1886(b)(7) of the Act establishes a payment methodology for 
new psychiatric hospitals and units, new rehabilitation hospitals and 
units, and new long-term care hospitals. Under the statutory 
methodology, for a hospital that is within a class of hospitals 
specified in the statute and first receives payments as a hospital or 
unit excluded from the prospective payment system on or after October 
1, 1997, the amount of payment will be determined as follows: For the 
first two 12-month cost reporting periods, the amount of payment is the 
lesser of (1) the operating costs per case; or (2) 110 percent of the 
national median of target amounts for the same class of hospitals for 
cost reporting periods ending during FY 1996, updated to the first cost 
reporting period in which the hospital receives payments as adjusted 
for differences in area wage levels.
    As discussed earlier, in reviewing our methodology for wage 
neutralizing the hospital-specific target amounts, it appears we 
incorrectly used the FY 2000 hospital inpatient prospective payment 
system wage index published in Tables 4A and 4B of the July 30, 1999 
final rule, which is based on wage data after taking into account 
geographic reclassifications under section 1886(d)(8) of the Act. 
Therefore, as we proposed in the May 4 proposed rule, we also are 
revising the methodology of wage neutralizing the hospital-specific 
target amounts using pre-reclassified wage data in our calculation of 
the limit for new excluded hospitals and units.
    The amounts included in the following table reflect the updated and 
recalculated 110 percent of the wage neutralized national median target 
amounts for each class of excluded hospitals and units for cost 
reporting periods beginning during FY 2002. These figures are updated 
to reflect the projected market basket increase of 3.3 percent. For a 
new provider, the labor-related share of the target amount is 
multiplied by the appropriate geographic area wage index, without 
regard to prospective payment system reclassifications, and added to 
the nonlabor-related share in order to determine the per case limit on 
payment under the statutory payment methodology for new providers.

------------------------------------------------------------------------
                                                  FY 2002      FY 2002
                                                   labor-     nonlabor-
     Class of  excluded  hospital or unit         related      related
                                                   share        share
------------------------------------------------------------------------
Psychiatric...................................       $6,815       $2,709
Rehabilitation................................      $13,465       $5,353
Long-Term Care................................      $16,701       $6,640
------------------------------------------------------------------------

b. Changes in Type of Hospital Classification (Secs. 412.23 and 412.25)
    Section 1886(b)(3) of the Act (as amended by section 4414 of Public 
Law 105-33) establishes caps on the target amounts for existing 
psychiatric hospitals and units, rehabilitation hospitals and units, 
and long-term care hospitals for cost reporting periods beginning on or 
after October 1, 1997 through September 30, 2002. Section 4416 of 
Public Law 105-33 amended section 1886(b)(7) of the Act to provide for 
a limitation on payment for new excluded psychiatric hospitals and 
units, new rehabilitation hospitals and units, and new long-term care 
hospitals. Since the establishment of the caps on target amounts and 
the payment limitations, there has been an increase in the number of 
hospitals requesting a change from one classification type to another 
(for example, from rehabilitation to long-term care). Regulations at 
Sec. 412.22(d) state that ``For purposes of exclusion from the 
prospective payment systems under this subpart, the status of each 
currently participating hospital (excluded or not excluded) is 
determined at the beginning of each cost reporting period and is 
effective for the entire cost reporting period. Any changes in the 
status of the hospital are made only at the start of a cost reporting 
period.''

[[Page 39917]]

Even though the existing regulations directly address only a hospital 
that changes from a prospective payment system hospital to an excluded 
hospital, our longstanding policy has been that a change of any 
classification type can be effective only at the beginning of the 
provider's cost reporting period. As we stated in the May 4 proposed 
rule, although the existing regulations do not directly address changes 
in a classification type of excluded hospital, we believe that a change 
from one classification type of excluded hospital to another type of 
excluded hospital is analogous to a change from a prospective payment 
system hospital to an excluded hospital. Therefore, based on our belief 
that it would be consistent with our longstanding policy, we proposed 
to amend our regulations to specify that a change from one excluded 
hospital classification type to another type is allowed only at the 
beginning of the hospital's cost reporting period.
    The rationale underlying our present policy of requiring that these 
types of changes should only be effective at the beginning of the cost 
reporting period is the need to avoid any undue (and possibly 
significant) administrative burden that could result from doing 
otherwise (for example, cost allocation, cost reporting requirements, 
certification issues). If we were to accept changes in an excluded 
hospital's classification type from one type of classification to 
another, other than at the beginning of the cost reporting period, the 
hospital would need to file a terminating cost report with respect to 
its original classification as well as file a separate cost report for 
the remainder of the cost reporting period with respect to its new 
classification. Filing these cost reports would involve gathering the 
appropriate cost data, allocating the data, and apportioning the data 
between the two hospital classes. Additionally, we would have to 
validate the cost reports. To allow these types of changes in the 
middle of a cost reporting period would result in a significant 
administrative burden. We point out that this burden is applicable 
equally for either a change from a prospective payment system hospital 
to an excluded hospital, or a change from one excluded hospital 
classification type to another classification type. Therefore, as we 
proposed in the May 4 proposed rule, we are amending the regulations to 
provide that the effective date of any of these classification changes 
is only at the beginning of a provider's cost reporting period 
(Sec. 412.23(i), for excluded hospitals, and Sec. 412.25(f), for 
excluded units).
    We did not receive any public comments on our proposed revisions of 
Secs. 412.23(i) and 412.25(f). Therefore, we are adopting the proposed 
revisions as final.
3. Effective Date of Exclusion of Long-Term Care Hospitals
    Existing regulations at Sec. 412.23(e) require a newly established 
long-term care hospital to operate for at least 6 months with an 
average length of stay in excess of 25 days in order to qualify for 
exclusion from the inpatient hospital prospective payment system as a 
long-term care hospital. Other regulations at Sec. 412.22(d) allow 
changes in a hospital's status from not excluded to excluded to occur 
only at the start of a cost reporting period. These two regulations, 
taken together, typically require a hospital to operate for at least 6 
months under the prospective payment system before becoming eligible 
for payment at the more favorable rate under section 1886(b)(3) of the 
Act.
    These regulations were challenged in litigation by a chain 
organization that operates a large number of long-term care hospitals 
(Transitional Hospitals Corporation of Louisiana, Inc. v. Shalala, 222 
F.3d 1019 (D.C. Cir. 2000) (THC)). Although the court of appeals in 
this case found that the Secretary has ample authority to adopt current 
regulatory provisions, it also concluded that the Secretary could have 
considered other policy options. Consequently, it remanded the case to 
the agency for the agency to consider whether it wanted to continue its 
existing policy or adopt a policy of either ``self-certification'' or 
``retroactive adjustment.'' Generally, under a self-certification 
approach, hospitals that have not yet demonstrated the required average 
length of stay would be excluded from the prospective payment system 
based on a commitment to maintain such a length of stay. Under a 
retroactive adjustment approach, a hospital's long-term care 
classification would be made effective with the beginning of the 6-
month period in which it demonstrated the required average length of 
stay. Payments for that period initially would be made under the 
prospective payment system and then adjusted retroactively to amounts 
payable for an excluded long-term care hospital once length of stay was 
successfully established.
    As directed by the court of appeals, we reviewed the issues raised 
in this case in light of the court's decision, and specifically 
considered the options of self-certification and retroactive 
adjustment. Our proposals, and the alternatives we considered before 
arriving at them, are explained in detail in the May 4, 2001 proposed 
rule (66 FR 22708) and summarized below.
    Although we understood that we have discretion to select other 
policy options, we proposed to continue our policy of requiring 
hospitals seeking long-term care hospital classification to demonstrate 
the required average length of stay based on 6 months of data, instead 
of permitting these hospitals to ``self-certify'' the required average 
length of stay.
    We noted that the statute provides the agency with broad authority 
to determine the methodology by which facilities can qualify for 
exclusion as long-term care hospitals (section 1886(d)(1)(B)(iv)(I) of 
the Act specifies that ``a hospital which has an average inpatient 
length of stay (as determined by the Secretary) of greater than 25 
days'' qualifies for exclusion as a long-term care hospital). As the 
court of appeals decided, the parenthetical phrase as determined by the 
Secretary ``gives the Secretary considerable leeway to determine 
whether to require prospective, contemporaneous, or retrospective 
evaluation and payment.'' (THC at 1026.)
    Having proposed to continue our policy of not allowing a hospital 
to self-certify the required average length of stay in order to be paid 
as an excluded long-term care hospital, we also considered the 
effective date of excluded status for a hospital that has demonstrated 
the required average length of stay. We considered making long-term 
care classification effective retroactively with the beginning of the 
6-month period in which the hospital demonstrated the required average 
length of stay. However, we believe that such retroactive application 
of excluded status is inappropriate.
    Therefore, we proposed to continue our policy that a hospital's 
payment as a long-term care hospital would be effective with the 
beginning of the hospital's cost reporting period that follows the 
determination to classify the hospital as a long-term care hospital.
    Comment: One commenter expressed general approval of the policies 
set forth in the May 4 proposed rule, stating that hospitals seeking 
long-term care status should be required to demonstrate the required 
length of stay based on 6 months of data.
    Response: We appreciate the support of the commenter for our 
proposed policy.
    Comment: Another commenter disagreed with our proposed policy and 
requested that we reconsider it. This commenter stated that our 
proposals were inconsistent with the purpose of

[[Page 39918]]

the prospective payment system exclusion, resulted in disparate 
treatment of similarly situated providers, and produced inappropriate 
reimbursement shortfalls. The commenter also argued that our reliance 
on the general prospective nature of the prospective payment system was 
misplaced and inconsistent with our regulations.
    Response: We have examined the commenter's contentions in detail 
but have concluded that they do not warrant adoption of a policy 
different from the one we have proposed. First, we disagree that our 
proposal is inconsistent with the purpose of the long-term care 
hospital exclusion. We agree with the commenter that the purpose of the 
exclusion is to ensure adequate reimbursement to hospitals that treat 
long-stay patients. However, the question addressed by our proposed 
policy is how to determine which providers meet the criteria for being 
considered hospitals that treat such patients. We believe that our 
proposed policy is the most appropriate methodology for making this 
determination. We believe that our proposed policy furthers the purpose 
of the exclusion by ensuring that only hospitals that can demonstrate 
compliance with the statutorily required length of stay receive long-
term care hospital status. It also ensures that decisions granting such 
status are implemented in accordance with the general goals of the 
prospective payment system and our longstanding policies regarding the 
effective dates of changes in the various components of providers' 
prospective payment system payment rates.
    Second, we do not agree with the commenter's contention that our 
proposed policy results in disparate treatment of similarly situated 
providers because we allow rehabilitation hospitals to self-certify 
that they will meet certain aspects of the criteria for exclusion but 
do not allow long-term care hospitals to do so. We dealt with this 
issue at length in the May 4 proposed rule and explained there that the 
differences in the nature of the two types of facilities, and the 
differences in their statutory and regulatory definitions, justified 
their varying treatment for these purposes. The commenter's assertion 
that the self-certification option that is permitted as to 
rehabilitation facilities and the same type of option that is not 
permitted as to long-term care hospitals both relate to the types of 
patient to be admitted--even if true in some general sense--is not 
sufficient in our view to overcome the clear differences in the two 
types of facilities that informs our different treatment of them.
    Similarly, the fact that long-term care hospitals must meet a 
series of regulatory conditions of participation does not make them 
sufficiently similar to rehabilitation hospitals so as to make the use 
of self-certification by long-term care hospitals appropriate, as the 
commenter suggested. All hospitals must meet conditions of 
participation to participate in the Medicare program. However, that 
does not change the fact that, as pointed out in the May 4 proposed 
rule, the statute itself requires that a hospital meet the length of 
stay criterion to qualify as a long-term care hospital, while the 
statute grants the Secretary broad authority to promulgate various 
criteria for a hospital to qualify as a rehabilitation hospital. It is 
the additional certainty supplied by the additional criteria for status 
as a rehabilitation hospital under this authority that has led us to 
allow rehabilitation hospitals to self-certify that they will comply 
with the remaining criterion. Such certainty is lacking in the case of 
long-term care hospitals, since the length-of-stay criterion is 
extremely difficult to predict into the future at any particular point 
in time.
    Conditions of participation exist as a matter of Medicare survey 
and certification activities to ensure that the provider meets the 
requirements of participation in the program, not as definitional 
criteria that establish a hospital's status for payment purposes. As a 
result, they do not provide the type of additional certainty that 
derives from the nature and number of rehabilitation hospital criteria 
and that might warrant allowing long-term care facilities to self-
certify that they will meet the required average length of stay. The 
commenter also pointed out that there are various criteria in 
Sec. 412.22(e) that a facility must meet to qualify as a hospital 
within a hospital. However, the existence of these criteria does not 
alter the fact that a hospital must meet the statutory length-of-stay 
criterion in order to qualify as a long-term care hospital, making 
self-certification by such a hospital inappropriate.
    The commenter suggested that, if we reject its suggestion to allow 
self-certification by long-term care hospitals, we should then adopt a 
policy whereby we would pay a long-term care hospital provisionally 
under the prospective payment system during its initial cost reporting 
period; evaluate compliance with the length-of-stay requirement at the 
end of that period; and, if the requirement had been met, retroactively 
adjust its reimbursement to provide for payment on a reasonable cost 
basis. We do not agree with the commenter that such a scheme would 
result in no significant administrative burden because the retroactive 
adjustments could be made as part of the cost report review process. 
Whether performed as part of this process or not, the scheme the 
commenter suggested would result in just the type of burden that has 
generally led to our making changes in components of the prospective 
payment system rates prospective only, as noted in the May 4 proposed 
rule. As also noted in the proposed rule, such prospective only changes 
are consistent with our approach, validated by the courts in cases like 
THC, Methodist Hospital of Sacramento, and County of Los Angeles, of 
balancing absolute accuracy and finality and favoring the latter in the 
context of the prospective payment system. We find nothing in the 
commenter's suggestions on this point that persuades us to depart from 
our intention to adopt our proposed policy.
    Third, we disagree with the commenter's statement that our proposed 
policy produces inappropriate reimbursement shortfalls. To the 
contrary, as noted above, our policy is designed to identify those 
hospitals that qualify for appropriate payment as long-term care 
facilities, in accordance with principles of prospectivity that have 
been approved by the courts. Although the commenter stated that 
Congress did not intend for us to require that new long-term care 
hospitals wait at least 6 months before being excluded from the 
hospital inpatient prospective payment system, the court of appeals in 
THC specifically found that the Medicare statute did not preclude just 
such a policy. We also note that, while the policy described in the May 
4 proposed rule is one of longstanding, Congress has never seen fit to 
amend the statute to require us to implement long-term care exclusions 
immediately upon a new hospital's participation in the program.
    Finally, we do not agree with the commenter that our reliance on 
the prospective nature of the prospective payment system in arriving at 
our proposed policy is misplaced or that the policy conflicts with our 
regulations. As to the former point, as noted above, we believe that 
the court decisions in THC, Methodist Hospital of Sacramento, and 
County of Los Angeles directly support the adoption of our proposed 
policy. We do not find the commenter's analyses of these cases 
persuasive. They cannot be distinguished on the basis that they apply 
to hospitals paid under the hospital inpatient prospective payment 
system but not to hospitals excluded

[[Page 39919]]

from the prospective payment system, as the commenter suggested. Making 
the determination whether a hospital is excluded from or subject to the 
hospital inpatient prospective payment is an important part of 
implementing the prospective payment system payment methodology, and, 
like other aspects of that implementation, should be guided by the 
general principles underlying the prospective payment system. That is 
especially so since the ``default'' payment mode for acute care 
hospitals is payment subject to the hospital inpatient prospective 
payment system, and reasonable cost payment does not result until it is 
determined (again, as part of administering the prospective payment 
system) that the hospital's status should change to excluded status.
    Moreover, while the court of appeals in Methodist Hospital may have 
stated that retroactive corrections are not necessarily inconsistent 
with the hospital inpatient prospective payment system, all three cases 
stand for the proposition that neither is the agency's prospective only 
policy inconsistent with the statute. Indeed, that is largely the point 
of the court of appeals' decision in THC--that the agency has broad 
statutory authority to adopt retroactive, contemporaneous, or 
prospective application of decisions granting long-term care status. 
For the reasons set out in the May 4 proposed rule and in this final 
rule, we have elected the latter policy. The policy at issue here is 
thus quite different from the one at issue in Georgetown University 
Hospital v. Bowen, 862 F.2d 323 (D.C. Cir.1988), which the commenter 
also cited, because the court of appeals held that that policy was 
contrary to express Congressional intent.
    Nor is our proposed policy contrary to our regulations. The only 
regulations that the commenter cited in support of this point are those 
that implement the statutory requirement that a hospital cost report be 
subject to retroactive adjustment upon review by the intermediary after 
the close of the applicable cost reporting period. However, those 
regulations, and the statutory provisions they implement, merely 
establish a year end ``book-balancing'' process to reconcile the amount 
of estimated payments made to the provider during the year with the 
actual amount of reimbursement the provider is due for that year, 
determined in accordance with the methods prescribed by the agency. 
Among those methods is prospective only application of the prospective 
payment system status decisions. These regulations then are in no way 
inconsistent with our proposed policy.
4. Payment for Long-Term Care Hospital Costs: Provisions of the June 
13, 2001 Interim Final Rule with Comment Period (Section 307 of Public 
Law 106-554 and 42 CFR 413.40(c)(4))
a. Increase in the Limitation on the Target Amounts for Long-Term Care 
Hospitals
    As stated in the June 13 interim final rule with comment period (66 
FR 32181), in the August 29, 1997 final rule with comment period (62 FR 
46018), in accordance with section 4414 of Public Law 105-33, we 
implemented section 1886(b)(3)(H) of the Act, which provides for caps 
on the target amounts for existing and new excluded hospitals and units 
for cost reporting periods beginning on or after October 1, 1997, 
through September 30, 2002. The caps on the target amounts apply to 
three classes of excluded hospitals: psychiatric hospitals and units, 
rehabilitation hospitals and units, and long-term care hospitals. In 
establishing the caps on the payment amounts within each class of 
hospital for new hospitals, section 1886(b)(7)(C) of the Act, as 
amended by section 4416 of Public Law 105-33, instructed the Secretary 
to provide an appropriate adjustment to take into account area 
differences in average wage-related costs. However, because the 
statutory language under section 4414 of Public Law 105-33 did not 
provide for the Secretary to adjust for area differences in wage-
related costs in establishing the caps on the target amounts within 
each class of hospital for existing hospitals, we did not adjust for 
wage-related differences for existing facilities. In the August 1, 2000 
interim final rule with comment period (65 FR 47039), we implemented 
section 121 of Public Law 106-113, which further amended section 
1886(b)(3)(H) of the Act by directing the Secretary to provide for an 
appropriate wage adjustment to the caps on the target amounts for all 
psychiatric hospitals and units, rehabilitation hospitals and units and 
long-term care hospitals, effective for cost reporting periods 
beginning on or after October 1, 1999, through September 30, 2002. For 
purposes of calculating the caps, section 1886(b)(3)(H)(ii) of the Act 
requires the Secretary to first ``estimate the 75th percentile of the 
target amounts for such hospitals within such class for cost reporting 
periods ending during fiscal year 1996.'' Section 1886(b)(3)(H)(iii) of 
the Act, as added by section 121 of Public Law 106-113, requires the 
Secretary to provide for ``an appropriate adjustment to the labor-
related portion of the amount determined under such subparagraph to 
take into account differences between average wage-related costs in the 
area of the hospital and the national average of such costs within the 
same class of hospital.''
    The August 1, 2000 final rule (65 FR 47096) listed the FY 2001 
labor-related share and nonlabor-related share of the national 75th 
percentile wage-neutralized cap for long-term care hospitals as 
follows:
     Labor-related Share: $29,284
     Nonlabor-related Share: $11,642

The final rule also discussed that within each class a hospital's wage-
adjusted cap on its target amount is determined by adding the 
hospital's nonlabor-related portion of the national wage-neutralized 
cap to its wage-adjusted labor-related portion of the national wage-
neutralized cap. A hospital's wage-adjusted labor-related portion is 
calculated by multiplying the labor-related portion of the national 
wage-neutralized 75th percentile cap for the hospital's class by the 
hospital's applicable wage index. For FY 2001, a hospital's applicable 
wage index is the wage index under the hospital inpatient prospective 
payment system as shown in Tables 4A and 4B of the August 1, 2000 final 
rule (65 FR 47149 through 47156) corresponding to the area in which the 
hospital is physically located (MSA or rural area).
    Section 307(a) of Public Law 106-554 further amended section 
1886(b)(3) of the Act and provides for a 2-percent increase to the 
wage-adjusted 75th percentile cap on the target amount for long-term 
care hospitals effective for cost reporting periods beginning during FY 
2001. This provision is only applicable to long-term care hospitals 
that were subject to the cap for existing excluded providers as 
specified in Sec. 413.40(c).
    In accordance with section 1886(b)(3) of the Act as amended, for 
cost reporting periods beginning during FY 2001, in the June 13 interim 
final rule with comment period, we specified the following revised 
labor-related and nonlabor-related shares of the cap on the target 
amount for long-term care hospitals, which reflect the 2-percent 
increase:

        Revised FY 2001 National Cap for Long-Term Care Hospitals
------------------------------------------------------------------------
    FY 2001 labor- related share       FY 2001 nonlabor- related share
------------------------------------------------------------------------
                $29,870                              $11,875
------------------------------------------------------------------------


[[Page 39920]]

    Note that the national 75th percentile wage-neutralized caps on the 
target amount for the other excluded hospitals and units subject to the 
caps under section 1886(b)(3)(H) of the Act (psychiatric and 
rehabilitation) are not affected by section 307 of Public Law 106-554. 
In the June 13 interim final rule with comment period, we revised the 
regulations at Sec. 413.40(c)(4)(iii) to incorporate this change.
    We did not receive any public comments on our proposed revision of 
Sec. 413.40(c)(4)(iii) to incorporate this provision of the statute 
and, therefore, are adopting it as final.
b. Increase in the Target Amounts for Long-Term Care Hospitals
    As stated in the June 13, 2001 interim final rule with comment 
period (66 FR 32181), in the August 29, 1997 final rule with comment 
period (62 FR 46016) we implemented the amendment to section 
1886(b)(3)(B) of the Act, as made by section 4411 of Public Law 105-33, 
which set forth the applicable rate-of-increase percentage for cost 
reporting periods beginning during FY 1999 through FY 2002. The rate-
of-increase is equal to the market basket increase percentage minus an 
amount based on the percentage by which the hospital's operating costs 
exceed the hospital's ceiling for the most recent available cost 
reporting period. The applicable rate-of-increase percentages (update 
factors) for FY 2001 are described in the August 1, 2000 final rule (65 
FR 47125). For FY 2001, the market basket increase percentage was 
forecast at 3.4 percent, which results in an update for long-term care 
hospitals for FY 2001 of between 0.9 percent and 3.4 percent, or 0 
percent, depending on the hospital's costs in relation to its rate-of-
increase limit.
    In addition to the increase to the cap on the target amounts for 
long-term care hospitals, section 307(a) of Public Law 106-554 also 
amended section 1886(b)(3) of the Act to provide for a 25-percent 
increase to the target amounts determined under section 1886(b)(3)(A) 
of the Act for long-term care hospitals, for cost reporting periods 
beginning in FY 2001, subject to the applicable cap on the target 
amounts. Thus, this provision required a revision to the determination 
of each long-term care hospital's FY 2001 target amount as specified in 
Sec. 413.40(c)(4). As stated in the June 13 interim final rule with 
comment period, for cost reporting periods beginning during FY 2001, 
the hospital-specific target amount otherwise determined for a long-
term care hospital as specified in the regulations at 
Sec. 413.40(c)(4)(ii) is multiplied by 1.25 (that is, increased by 25 
percent), subject to the limitation that the revised FY 2001 target 
amounts for a long-term care hospital cannot exceed its wage-adjusted 
national cap as required by section 1886(b)(3) of the Act, as amended 
by section 307(a) of Public law 106-554. We noted that the 25-percent 
increase to the target amount under section 307(a) of Public Law 106-
554 is applicable only to long-term care hospitals, and not to other 
excluded hospitals as defined in section 1886(d)(1)(B) of the Act 
(psychiatric and rehabilitation hospitals and units, children's and 
cancer hospitals).
    In the June 13, 2001 interim final rule with comment period, we 
revised the regulations at Sec. 413.40(c)(4)(iii) to incorporate this 
change.
    We did not receive any public comments on this revision of 
Sec. 413.40(c)(4)(iii) to incorporate this provision of the statute 
and, therefore, are adopting it as final.
5. Development of Prospective Payment System for Inpatient 
Rehabilitation Hospitals and Units
    Section 1886(j) of the Act, as added by section 4421 of Public Law 
105-33, provided the phase-in of a case-mix adjusted prospective 
payment system for inpatient rehabilitation services (freestanding 
hospitals and units) for cost reporting periods beginning on or after 
October 1, 2000 and before October 1, 2002, with a fully implemented 
system for cost reporting periods beginning on or after October 1, 
2002. Section 1886(j) of the Act was amended by section 125 of Public 
Law 106-113 to require the Secretary to use the discharge as the 
payment unit under the prospective payment system for inpatient 
rehabilitation services and to establish classes of patient discharges 
by functional-related groups. Section 305 of Public Law 106-554 further 
amended section 1886(j) of the Act to allow hospitals to elect to be 
paid the full Federal prospective payment rather than the transitional 
period payments specified in the Act.
    Shortly, we will be issuing a final rule on the establishment of 
the prospective payment system for inpatient rehabilitation facilities, 
to be effective January 1, 2002.
6. Increase in the Incentive Payment for Excluded Psychiatric Hospitals 
and Units: Provision of the June 13, 2001 Interim Final Rule with 
Comment Period (Section 306 of Public Law 106-554 and 42 CFR 
413.40(d)(2))
    As we stated in the June 13 interim final rule with comment period 
(66 FR 32181), for cost reporting periods beginning before October 1, 
1997, a hospital that had inpatient operating costs less than, or equal 
to, its ceiling was paid its costs plus the lower of 50 percent of the 
difference between inpatient operating costs and the ceiling or 5 
percent of the ceiling. Section 4415 of Public Law 105-33 amended 
section 1886(b)(1)(A) of the Act to provide that for cost reporting 
periods beginning on or after October 1, 1997, if a hospital's net 
inpatient operating costs are less than or equal to, the ceiling, the 
amount of the bonus payment would be the lower of 15 percent of the 
difference between the inpatient operating costs and the ceiling or 2 
percent of the ceiling. Section 306 of the Public Law 106-554 further 
amended section 1886(b)(1)(A) of the Act, as it applied to a 
psychiatric hospital or unit, to provide that effective for cost 
reporting periods beginning on or after October 1, 2000, and before 
October 1, 2001, if a psychiatric hospital or unit's net inpatient 
operating costs are less than, or equal to, the ceiling, the amount of 
the bonus payment is the lower of 15 percent of the difference between 
the inpatient operating costs and the ceiling, or 3 percent of the 
ceiling.
    In the June 13 interim final rule with comment period, we revised 
the regulations at Sec. 413.40(d)(2) to incorporate this change.
    We did not receive any public comments on our revision to 
Sec. 413.40(d)(2) in the interim final rule with comment period to 
incorporate this provision of the statute and, therefore, are adopting 
it as final.
7. Changes in the Types of Patients Served or Inpatient Care Services 
That Distort the Comparability of a Cost Reporting Period to the Base 
Year are Grounds for Requesting an Adjustment Payment in Accordance 
with Section 1886(b)(4) of the Act
    Section 4419(b) of Public Law 104-33 requires the Secretary to 
publish annually in the Federal Register a report describing the total 
amount of adjustment (exception) payments made to excluded hospitals 
and units, by reason of section 1886(b)(4) of the Act, during the 
previous fiscal year. However, the data on adjustment payments made 
during the previous fiscal year are not available in time to publish a 
report describing the total amount of adjustment payments made to all 
excluded hospitals and units in the subsequent year's final rule 
published in the Federal Register.
    The process of requesting, adjudicating, and awarding an adjustment 
payment for a given cost reporting period occurs over a 2-year

[[Page 39921]]

period or longer. An excluded hospital or unit must first file its cost 
report for the previous fiscal year with its intermediary within 5 
months after the close of the previous fiscal year. The fiscal 
intermediary then reviews the cost report and issues a Notice of 
Program Reimbursement (NPR) in approximately 2 months. If the 
hospital's operating costs are in excess of the ceiling, the hospital 
may file a request for an adjustment payment within 6 months from the 
date of the NPR. The intermediary, or CMS, depending on the type of 
adjustment requested, then reviews the request and determines if an 
adjustment payment is warranted. This determination is often not made 
until more than 6 months after the date the request is filed. 
Therefore, it is not possible to provide data in a final rule on 
adjustments granted for cost reports ending in the previous Federal 
fiscal year, since those adjustments have not even been requested by 
that time. However, in an attempt to provide interested parties at 
least some relevant data on adjustments, we are publishing data on 
requests for adjustments that were processed by the fiscal 
intermediaries or CMS during the previous Federal fiscal year.
    The table below includes the most recent data available from the 
intermediaries and CMS on adjustment payments that were adjudicated 
during FY 2000. By definition, these were for cost reporting periods 
ending in years prior to FY 1999. The total adjustment payments awarded 
to excluded hospitals and units during FY 2000 are $12,344,419. The 
table depicts for each class of hospital, in aggregate, the number of 
adjustment requests adjudicated, the excess operating cost over the 
ceiling, and the amount of the adjustment payment.

------------------------------------------------------------------------
                                                Excess cost
         Class of hospital             Number       over      Adjustment
                                                  ceiling      payment
------------------------------------------------------------------------
Psychiatric........................         40  $19,172,613   $9,114,944
Rehabilitation.....................          8    6,128,515    2,254,393
Long-Term Care.....................          3      827,821      814,971
Children's.........................          1      160,111      160,111
------------------------------------------------------------------------

B. Critical Access Hospitals (CAHs)

    Section 4201 of Public Law 105-33 amended section 1820 of the Act 
to create a nationwide Medicare Rural Hospital Flexibility (MRHF) 
Program to replace the 7-State Essential Access Community Hospital/
Rural Primary Care Hospital (EACH/RPCH) program. Under section 
1820(c)(2) of the Act, as amended, a State could designate certain 
rural hospitals as CAHs if they were located a specified distance from 
other hospitals, made 24-hour emergency care available, and kept 
inpatients for a limited period of time. Additionally, CAH staffing 
requirements differed from those of other hospitals under Medicare and 
CAHs received payment for inpatient and outpatient services on the 
basis of reasonable cost. A comprehensive discussion of CAHs within the 
context of the MRHF Program may be found in the August 29, 1997 Federal 
Register (62 FR 45970 and 46008-46010).
1. Permitting Certain Facilities to be Designated as CAHs (Section 
401(b) of Public Law 106-113 and 42 CFR 485.610)
    As discussed in the August 1, 2000 interim final rule with comment 
period, one of the threshold criteria for designation as a CAH under 
section 1820(c)(2)(B)(i) of the Act is that the hospital must be rural 
as defined in section 1886(d)(2)(D)(ii) of the Act. Section IV.A. of 
the interim final rule with comment period discussed the option of 
urban to rural classification for a ``subsection (d)'' hospital 
authorized by section 401(a) of Public Law 106-113 under an amendment 
to section 1886(d)(8) of the Act. Section 401(b)(2) of Public Law 106-
113 amended section 1820(c)(2)(B) of the Act to authorize a State to 
designate a hospital in an urban area as a CAH if, under one of the 
criteria set forth in section 1886(d)(8)(E) of the Act, it would be 
treated as being located in the rural area of the State in which the 
hospital is located. Section 401(b)(2) only provides authority for a 
hospital to meet the rural requirement. We note that the hospital would 
have to otherwise meet the statutory and regulatory requirements 
governing CAH designation.
    The first criteria in section 401(a) specified that a hospital will 
be treated as located in a rural area if the hospital is located in a 
rural census tract of an MSA, as determined under the most recent 
Goldsmith Modification, originally published in the Federal Register on 
February 27, 1992. In Appendix B of the August 1, 2000 interim final 
rule with comment period, we published a listing of existing hospitals 
that may qualify as CAHs because they are located in Goldsmith areas.
    In the August 1, 2000 interim final rule, we specified that the 
application procedures and effective dates for an urban hospital 
seeking to reclassify as rural in order to apply for CAH status under 
section 1820(c)(2)(B)(i) of the Act were set forth in new Sec. 412.103 
that implements section 401(a), and discussed in section IV.C. of that 
interim final rule with comment period (65 FR 47041). In the August 1 
interim final rule with comment period, we revised the regulations on 
location for CAHs at Sec. 485.610(b) to reflect this amendment.
    We did not receive any comments on the revised section of the 
regulations in the interim final rule with comment period and have not 
made any further changes to it.
2. Exclusion of CAHs From Payment Window Requirements
    Section 1886 of the Act specifies the requirements governing 
payment to full-service hospitals for the operating costs of inpatient 
hospital services under both the inpatient hospital prospective payment 
system and the limits on the target amounts for hospitals excluded from 
the prospective payment system. ``Operating costs of inpatient hospital 
services'' are defined in section 1886(a)(3) of the Act, which provides 
in part that costs of certain services provided to a beneficiary during 
the 3 days (or in the case of an excluded hospital or unit, during the 
1 day) immediately preceding the patient's admission are to be included 
in the payments for costs under the inpatient hospital prospective 
payment system, or costs subject to the target amount for excluded 
hospitals and units. This part of the definition is sometimes referred 
to as the ``payment window'' requirement. Regulations implementing the 
payment window requirement are found at Sec. 412.2(c)(5) for hospitals 
subject to the prospective payment system, and Sec. 413.40(c)(2) for 
hospitals excluded from the prospective payment system.
    As we stated in the May 4, 2001 proposed rule, payment to CAHs for 
inpatient services is not made under the

[[Page 39922]]

inpatient hospital prospective payment system mandated by section 1886 
of the Act, nor are CAHs considered to be hospitals excluded from the 
inpatient hospital prospective payment system. Instead, payment is made 
on a reasonable cost basis, as mandated by section 1814(l) of the Act. 
Neither section 1814(l) nor section 1861(v) of the Act (which defines 
``reasonable cost'') requires application of the payment window to 
services furnished on an outpatient basis immediately before admission 
to a CAH. Therefore, we stated in the May 4 proposed rule that we have 
determined that the payment window provision does not apply to CAHs. To 
clarify this point and avoid possible misapplication of the payment 
window, we proposed to amend Sec. 413.70(a)(l) to provide that the 
requirements of Secs. 412.2(c)(5) and 413.40(c)(2) do not apply to 
CAHs.
    Comment: Several commenters expressed support for the proposal to 
explicitly exclude CAHs from the payment window requirements. None of 
the commenters opposed the proposal or suggested changes to it.
    Response: We appreciate the commenters' support and are adopting 
the proposed regulation amendments as final.
3. Availability of CRNA Pass-Through for CAHs
    Generally, anesthesia services furnished to a hospital patient by a 
certified registered nurse anesthetist (CRNA) must be billed to the 
Part B carrier and payment is made under the applicable fee schedule 
provisions of Sec. 414.60. However, certain rural hospitals that 
furnish no more than 500 surgical procedures requiring anesthesia per 
year and meet other specified requirements are exempted from the fee 
schedule. These hospitals are paid on a reasonable cost basis for their 
costs of anesthesia services furnished by qualified nonphysician 
anesthetists. The exemption is provided in accordance with section 
9320(k) of the Omnibus Budget Reconciliation Act of 1986 (Public Law 
99-509) (as added by section 608(c)(2) of the Family Support Act of 
1988 (Public Law 100-185), as amended by section 6132 of the Omnibus 
Budget Reconciliation Act of 1989 (Public Law 101-239)). We have 
codified this exemption at Sec. 412.113(c).
    We pointed out in the May 4 proposed rule that, although 
Sec. 412.113(c) does not specifically extend eligibility for the pass-
through payment for CRNAs to CAHs, some CAHs have pointed out that they 
are similar to the rural hospitals that are eligible for this payment, 
in that they also furnish low volumes of surgical procedures requiring 
anesthesia and could face the same problem of potentially inadequate 
payment for CRNA services if they are not allowed to qualify for the 
pass-through payment. We share this concern.
    We recognize that the legislation cited above, which provides the 
legal basis for the pass-through payments, refers only to 
``hospitals,'' not to CAHs. Moreover, section 1861(e) of the Act states 
that ``the term ``hospital'' does not include, unless the context 
otherwise requires, a critical access hospital * * *.'' It is clear 
from section 1861(e) of the Act that CAHs are not to be considered 
hospitals under the Medicare law for most purposes. However, the 
reference to ``context'' in the provision indicates that CAHs may be 
classified as hospitals where, in specific contexts, it would be 
consistent with the purpose of the legislation to do so.
    We stated that we believe this is the case with the statutory 
provisions authorizing pass-through payments for CRNA costs. The 
purpose of the pass-through legislation is to provide small rural 
hospitals with low surgical volumes with relief from the difficulties 
they might otherwise have in furnishing CRNA services for their 
patients. CAHs are by definition limited-service facilities located in 
rural areas and, as such, they serve a population much like those 
served by hospitals eligible for the pass-through payments. In some 
cases, an institution that now participates as a CAH may even have been 
eligible for the pass-through payments when it participated as a 
hospital. Such an institution would clearly be disadvantaged if it were 
to lose this status. Thus, in accordance with section 1861(e) of the 
Act and in light of the context of the pass-through legislation cited 
above, we consider CAHs to be ``hospitals'' for purposes of extending 
eligibility for the CRNA pass-through payments to them.
    Therefore, in the May 4 proposed rule, we proposed to add a new 
Sec. 413.70(a)(3) and revise Secs. 413.70(a)(2), (b)(1), and (b)(6) to 
permit CAHs that meet the criteria for the pass-through payments in 
Sec. 412.113(c) to qualify for pass-through payments for the costs of 
anesthesia services for both inpatient and outpatient surgeries, on the 
same basis as full service rural hospitals. As an unrelated technical 
correction, we proposed to revise Sec. 413.70(b)(2)(i)(C) to delete the 
incorrect reference to Sec. 413.130(j)(2) and replace it with a 
reference to reduction in capital costs under Sec. 413.130(j). We also 
proposed to revise Sec. 412.113(c) by changing the term ``hospital'' to 
``hospital or CAH''.
    Comment: Several commenters favored extension of the CRNA pass-
through to CAHs. However, some commenters suggested that the pass-
through be made available to all CAHs, even if they furnish 500 or more 
surgical procedures requiring anesthesia service in the prior year.
    Response: Section 412.113(c), which is based on the provisions of 
the Medicare law, is specific with respect to the volume of surgeries 
that may be performed by facilities qualifying for the CRNA pass-
through. The volume of surgeries is a criterion for a hospital to 
qualify for CRNA pass-through. As we are treating CAHs as hospitals for 
purposes of the CRNA pass-through, a CAH would have to meet the same 
qualifying criteria as would a hospital. Accordingly, we are not 
adopting the commenters' suggestion that the 500 procedure criterion be 
revised for CAHs.
    Comment: One commenter stated that anesthesia services in many 
rural facilities are furnished by anesthesiologists rather than CRNAs, 
and suggested that pass-through also be made available for the costs of 
anesthesia services provided by anesthesiologists.
    Response: The Medicare law is specific to CRNAs and does not offer 
similar treatment for costs of services of anesthesiologists. 
Therefore, we are not adopting this suggestion.
4. Payment to CAHs for Emergency Room On-Call Physicians 
(Sec. 413.70(b)(4))
    Under section 1834(g) of the Act, Medicare payment to a CAH for 
facility services to Medicare outpatients is the reasonable costs of 
the CAH in providing such services. The term ``reasonable cost'' is 
defined in section 1861(v) of the Act and in regulations at 42 CFR Part 
413, including, with specific reference to CAHs, Sec. 413.70. 
Consistent with the general policies stated in section 2109 of the 
Medicare Provider Reimbursement Manual (PRM), Part I (HCFA Publication 
15-1), the reasonable cost of CAH services to outpatients may include 
reasonable costs of compensating physicians who are on standby status 
in the emergency room (that is, physicians who are present and ready to 
treat patients if necessary). However, under existing policy, the 
reasonable cost of CAH services to outpatients may not include any 
costs of compensating physicians who are not present in the facility 
but are on call.
    Section 204 of Public Law 106-554 further amended section 1834(g) 
of the Act (as amended by section 201 of Public Law 106-554) by adding 
a new

[[Page 39923]]

paragraph (5). New section 1834(g)(5) of the Act provides that, in 
determining the reasonable costs of outpatient CAH services under 
sections 1834(g)(1) and 1834(g)(2)(A) of the Act, the Secretary shall 
recognize as allowable costs amounts (as defined by the Secretary) for 
reasonable compensation and related costs for emergency room physicians 
who are on call (as defined by the Secretary) but who are not present 
on the premises of the CAH involved, are not otherwise furnishing 
physicians' services, and are not on call at any other provider or 
facility. The provisions of section 204 of Public Law 106-554 are 
effective for cost reporting periods beginning on or after October 1, 
2001.
    As we provided in the May 4 proposed rule, to implement the 
provisions of section 1834(g)(5) of the Act, we proposed to add a new 
paragraph (4) to Sec. 413.70(b). The proposed Sec. 413.70(b)(4) would 
permit the reasonable costs of CAH outpatient services to include the 
reasonable compensation and related costs of emergency room on-call 
physicians under the terms and conditions specified in the statute. As 
directed in the statute, under Sec. 413.70(b)(4)(ii)(A) of the proposed 
rule, we defined ``amounts for reasonable compensation and related 
costs'' as those allowable costs of compensating emergency room 
physicians for being on call, to the extent these costs are found to be 
reasonable under the rules in Sec. 413.70(b)(2).
    In addition, as specified under Sec. 413.70(b)(4)(ii)(A) of the 
proposed rule, we defined an ``emergency room physician who is on 
call'' as a doctor of medicine or osteopathy with training or 
experience in emergency care who is immediately available by telephone 
or radio contact, and who is available on site within the timeframes 
specified in our existing regulations under Sec. 485.618(d). Existing 
Sec. 485.618(d) specifies that the physician must be available on site 
(1) Within 30 minutes, on a 24-hour a day basis, if the CAH is located 
in an area other than an area described in item (2); or (2) within 60 
minutes, on a 24-hour a day basis, if all of the following requirements 
are met:
     The CAH is located in an area designated as a frontier 
area (that is, an area with fewer than six residents per square mile 
based on the latest population data published by the Bureau of the 
Census) or in an area that meets criteria for a remote location adopted 
by the State in its rural health care plan, and approved by HCFA, under 
section 1820(b) of the Act.
     The State has determined under criteria in its rural 
health care plan that allowing an emergency response time longer than 
30 minutes is the only feasible method of providing emergency care to 
residents of the area served by the CAH.
     The State maintains documentation showing that the 
response time of up to 60 minutes at a particular CAH it designates is 
justified because other available alternatives would increase the time 
needed to stabilize a patient in an emergency.
    We also believe that it is essential that physicians who are paid 
to be in on-call status in fact come to the facility when summoned. 
Therefore, we proposed to specify that costs of on-call emergency room 
physicians are allowable only if the costs are incurred under written 
contracts that require them to come to the CAH when their presence is 
medically required.
    Comment: One commenter noted that existing regulations at 
Sec. 413.70(a)(2) prohibit application, in making reasonable cost 
determinations for CAHs, of the reasonable compensation equivalent 
(RCE) limits on physician services to providers. The commenter 
expressed concern that more explicit reasonableness guidelines may be 
needed to ensure that costs recognized for on-call services are 
reasonable.
    Response: We understand the commenter's concern, but note that 
existing reasonable cost rules at Sec. 413.9(c)(2) authorize 
intermediaries to disallow costs of services that are ``substantially 
out of line'' with costs of other, similar providers in the same area. 
We will continue to monitor these costs and will consider proposing 
further or more specific reasonableness standards if necessary.
    Comment: One commenter stated that contracts for emergency services 
are typically executed between a CAH and a physician group, and, for 
legal purposes, the individual physician is not distinguishable from 
the group. The commenter further stated that if the regulations 
prohibit the ``physician'' from otherwise furnishing services or being 
on call at another facility, the proposed language of the regulation 
may inadvertently prohibit any member of the physicians group from 
otherwise furnishing services or being on call.
    Response: We have reconsidered the proposed language of 
Sec. 413.70(b)(4) in the light of this comment, but find no basis for 
interpreting the proposed revised language in the way the commenter has 
suggested may occur. The proposed revised language makes it clear that 
it is the individual physician who is on call for the CAH that may not 
be otherwise engaged in furnishing physician's services, or on call at 
another provider or facility.
    We are adopting proposed Sec. 413.70(b)(4) as final.
5. Treatment of Ambulance Services Furnished by Certain CAHs 
(Sec. 413.70(b)(5))
    Under section 1861(s)(7) of the Act, Medicare Part B covers and 
pays for ambulance services, to the extent prescribed in regulations, 
when the use of other methods of transportation would be 
contraindicated. Various Congressional reports indicate that Congress 
intended that (1) the ambulance benefit cover transportation services 
only if other means of transportation are contraindicated by the 
beneficiary's medical condition; and (2) only ambulance services to 
local facilities be covered unless necessary services are not available 
locally, in which case, transportation to the nearest facility 
furnishing those services is covered. (H.R. Rept. No. 89-213, 89th 
Cong., 1st Sess. at 37 (1995) and S. Rept. No. 89-404, 89th Cong., 1st 
Sess., Pt. I, at 43 (1995).
    The Medicare program currently pays for ambulance services on a 
reasonable cost basis when furnished by a provider and on a reasonable 
charge basis when furnished by a supplier. (The term ``provider'' 
includes all Medicare-participating institutional providers that submit 
claims for Medicare ambulance services (hospitals, CAHs, SNFs, and home 
health agencies).) The term ``supplier'' means an entity that is 
independent of any provider. The reasonable charge methodology that is 
the basis of payment for ambulance services is determined by the lowest 
of the customary, prevailing, actual, or inflation indexed charge.
    Section 4531(a)(1) of Public Law 105-33 amended section 1861(v)(1) 
of the Act and imposed an additional per trip limitation on reasonable 
cost payment to hospitals and CAHs for ambulance service. As amended, 
the statute provides that, in determining the reasonable cost of 
ambulance services furnished by a provider of services, the Secretary 
shall not recognize the cost per trip in excess of the prior year's 
reasonable cost per trip updated by an inflation factor. This trip 
limit provision was first effective for services furnished during 
Federal fiscal year 1998 (October 1, 1997 through September 30, 1998).
    Section 205 of Public Law 106-554 amended section 1834(l) of the 
Act by adding a new paragraph (8) to that section. New section 
1834(l)(8) provides that the Secretary is to pay the reasonable costs 
incurred in furnishing ambulance services if such services are

[[Page 39924]]

furnished by a CAH (as defined in section 1861(mm)(1) of the Act), or 
by an entity owned and operated by the CAH. This provision in effect 
eliminates any trip limit that CAHs had been subject to as a result of 
section 1861(v)(1) of the Act, as amended by Public Law 105-33. 
However, section 205 further states that in order to receive reasonable 
cost reimbursement for the furnishing of ambulance services, the CAH or 
entity must be the only provider or supplier of ambulance services 
located within a 35-mile drive of the CAH. Section 205 is effective for 
services furnished on or after December 21, 2000, the date of enactment 
of Public Law 106-554.
    As stated in the May 4 proposed rule, to implement the provisions 
of section 1834(l)(8) of the Act, we proposed to add a new paragraph 
(5) to Sec. 413.70(b) to permit a CAH, or an entity owned or operated 
by a CAH, to be paid for furnishing ambulance services on a reasonable 
cost basis if the CAH or entity is the only provider or supplier of 
ambulance services within a 35-mile drive of the CAH. In determining 
whether there is any other provider or supplier of ambulance services 
within a 35-mile drive of a CAH or entity, we first identify the site 
where the nearest other ambulance provider or supplier garages its 
vehicles, and then determine whether that site is within 35 miles, 
calculated as the shortest distance in miles measured over improved 
roads. An improved road for this purpose is be defined as any road that 
is maintained by a local, State, or Federal government entity, and is 
available for use by the general public. Consistent with the change, in 
the May 4 proposed rule concerning Sec. 412.92(c)(1) relating to SCH 
determinations (as explained in section IV.A. of this preamble), we 
proposed to consider improved roads to include the paved surface up to 
the front entrance of the hospital and, for purposes of 
Sec. 413.70(b)(5), the front entrance of the garage.
    Comment: Several commenters recommended that we support a 
legislative change that would eliminate the 35-mile requirement and 
allow all designated CAHs owning ambulance services to be reimbursed at 
cost. Another commenter requested that we support a legislative change 
to address situations where the distance requirement involves 
mountainous terrain or only secondary roads and that in such cases the 
mileage requirement be 15 miles.
    Response: As the commenters pointed out, the statute as currently 
worded is clear as to applicability of the 35-mile rule in connection 
with the requirements for cost reimbursement of ambulance services 
furnished by CAHs. Therefore, we are not making any changes in the 
final regulation based on these comments.
    Comment: One commenter described a situation where both the CAH and 
ambulance services are wholly owned by a city but the CAH provides 
operating services to the ambulance company. The commenter asked 
whether in such a case the ambulance services could be considered to be 
furnished by an entity that is wholly owned and operated by the CAH.
    Response: As stated in section 205 of the Public Law 106-554, 
payment on a reasonable cost basis may be made for ambulance services 
furnished by a CAH, or an entity owned and operated by the CAH. The 
legislation does not allow us to extend similar treatment to ambulance 
services that may be operated but not owned by a CAH. Accordingly, we 
are not making any changes in this final rule based on this comment.
    We are adopting proposed Sec. 413.70(b)(5) as final without change.
6. Qualified Practitioners for Preanesthesia and Postanesthesia 
Evaluation in CAHs
    Section 1820 of the Act sets forth the conditions for designating 
certain hospitals as CAHs. Implementing regulations for section 1820 of 
the Act are located in 42 CFR part 485, Subpart F. Included in the 
conditions of participation regulations for CAHs in subpart F is the 
condition for surgical services (Sec. 485.639). Existing Sec. 485.639 
specifies that preanesthesia and postanesthesia services in a CAH can 
only be performed by a doctor of medicine or osteopathy, including an 
osteopathic practitioner recognized under section 1101(a)(7) of the 
Act; a doctor of dental surgery or dental medicine; or a doctor of 
podiatric medicine. This Medicare condition of participation 
requirement regarding preanesthesia and postanesthesia evaluations for 
CAHs differs from, and is more restrictive than, the current 
requirement for acute care hospitals in general. In an acute care 
hospital, the CRNA is listed among the practitioners who may perform 
the preanesthesia and postanesthesia evaluations.
    Our principal consideration in regulating providers is to ensure 
patient safety and high quality patient outcomes. As circumstances and 
health care environments change, we reassess regulations and propose 
changes accordingly.
    In the May 4 proposed rule, we stated that when the regulations for 
the initial Rural Primary Care Hospital (RPCH) program (which later 
became the CAH program) were adopted, RPCHs were limited to patient 
stays of no more than 72 hours and to bed counts of no more than 6 
acute care beds. We initially viewed RPCHs as very limited-service 
facilities that would be unlikely to perform any surgery beyond what 
might be done in a physician's office; therefore, we did not have a 
condition of participation for surgery. Section 102(a)(1) of the Social 
Security Amendments of 1994, Public Law 103-432, specifically 
authorized surgical care in RPCHs. In June 1995, we proposed a surgical 
condition of participation that incorporated the ambulatory surgery 
center (ASC) standards. We expected that the types of procedures done 
in a RPCH would most likely be those that could be done in ASCs. At the 
time, we received no comments in response to the proposed standards and 
therefore adopted them in the final RPCH conditions of participation 
that were published on September 1, 1995 (60 FR 45851).
    In 1997, the RPCH (now CAH) program was expanded through a 
statutory change to include all States and to allow for an increase in 
bed size and length of stay (August 29, 1997 final rule, 62 FR 46035). 
Since that time, the program's original conditions of participation 
have been revised (and more recently have been proposed to be revised) 
to remove possible barriers to access to care. One example of our 
latest effort is our proposed rule to eliminate the Federal requirement 
for physician supervision of CRNAs in CAHs as well as in acute care 
hospitals and ASCs that was published in the Federal Register on 
January 18, 2001 (66 FR 96570).
    Recently, provider and medical groups have suggested that CAHs may 
be at risk of losing the ability to provide access to appropriate 
surgical services without the full support of available CRNAs. They 
indicated that the existing regulations place the responsibility of the 
preanesthesia and postanesthesia evaluations on the operating 
practitioner, thereby creating a higher standard for CAHs than for 
other hospitals.
    In an effort to eliminate or minimize potential access issues in 
rural areas and to recognize the CAH's program expansion, in the May 4, 
2001 proposed rule, we proposed to revise Sec. 485.639(b) to allow 
CRNAs to perform preanesthesia and postanesthesia evaluations in a CAH. 
As with any licensed independent health care provider, the proposed 
change would not permit CRNAs to practice beyond his or her licensed 
scope of practice or

[[Page 39925]]

the approved policies and procedures of the CAH.
    We received 26 comments on our proposal.
    Comment: Almost all of the 26 commenters supported our proposed 
change to the existing CAH conditions of participation to remove the 
requirement that only physicians can perform the preanesthesia and 
postanesthesia evaluations. The proposed regulation includes CRNAs 
among the practitioners that may perform these services. The commenters 
stated that the existing anesthesia evaluation requirements for CAHs 
are more restrictive than the requirements for hospitals and they 
impose an unnecessary burden on operating surgeons and the facilities.
    Response: We appreciate the commenters' support.
    Comment: One commenter stated that the proposed amendment to the 
condition of participation for surgical services under Sec. 485.639(b) 
is ill-advised and should not be adopted, or, at the very least, should 
be postponed until the regulation regarding physician supervision of 
CRNAs in hospitals is finalized.
    Response: The commenter correctly notes that we have not finalized 
the regulation to amend the physician supervision requirement for CRNAs 
(66 FR 96570, January 18, 2001). Our proposal that CRNAs perform 
preanesthesia and postanesthesia evaluations in CAHs in our May 4, 2001 
proposed rule does not conflict with the January 18, 2001 proposed 
physician supervision regulation because our proposal does not affect 
current requirements for CRNAs, such as physician supervision. We 
mentioned the proposed physician supervision regulation in the preamble 
to the May 4 proposed rule as an example of our continual effort to 
review and evaluate our policies and regulations to better facilitate 
patient access and improve patient outcomes.
    Comment: One commenter stated that there is no basis for us to 
assume that the safety-oriented anesthesia standards for CAHs should be 
any less stringent than those applicable to ambulatory surgical centers 
(ASCs).
    Response: We acknowledge the commenter's concern regarding the 
anesthesia risk and evaluation standard for ASCs. Our existing 
conditions for coverage for ASCs require examination of patients by a 
physician immediately before surgery to evaluate the risk of anesthesia 
and of the procedure to be performed. The ASC conditions for coverage 
also require evaluation of patients by a physician for proper 
anesthesia recovery prior to discharge from the ASC. We expect to 
review and modify the ASC condition of coverage, including the current 
anesthesia risk and evaluation standard, through a notice of proposed 
rulemaking in 2002. At that time, we will consider the commenter's 
concern.
    Comment: One commenter stated that according to a recent national 
survey of one-third of rural hospital chief executives, almost 80 
percent of the respondents reported that their institutions perform 
high-complexity surgery, such as gall bladder and stomach surgery. The 
commenter further stated that the hospital conditions of participation 
require that the preoperative evaluation be conducted by an individual 
qualified to administer anesthesia, but in the cases of a nurse 
anesthetist, the anesthesia provider must work under the supervision of 
the operating practitioner or an anesthesiologist. As such, the 
commenter summarized that the hospital requirements are not less 
stringent than the CAH requirements.
    Response: The commenter has misunderstood the proposal to mean that 
physician supervision for CRNAs is eliminated. The proposed regulation, 
as noted in response to a previous comment, will not remove physician 
supervision of CRNAs.
    Unlike in acute care hospitals, CRNAs are currently listed among 
the qualified practitioners who can administer anesthesia under 
physician supervision in CAHs but they cannot perform the preanesthesia 
and postanesthesia evaluations. In response to the provider industry's 
concerns with access to care, our proposal was that CRNAs be allowed to 
perform preanesthesia and postanesthesia evaluations.
    We are adopting the proposed Sec. 485.639(b) as final without 
change.
7. Clarification of Location Requirements for CAHs (Secs. 485.610(b) 
and (c))
    Under section 1820(c)(2)(B)(i) of the Act, a facility seeking 
designation by the State as a CAH must meet two distinct types of 
location requirements. First, the facility must either be actually 
located in a county or equivalent unit of local government in a rural 
area, as defined in section 1886(d)(2)(D) of the Act, or it must be 
located in an urban area as defined in section 1886(d)(2)(D) of the 
Act, but be treated as being located in a rural area under section 
1886(d)(8)(E) of the Act. Second, the facility must also be located 
more than a 35-mile drive (or, in the case of mountainous terrain or in 
areas with only secondary roads available, a 15-mile drive) from a 
hospital or similar facility described in section 1820(c) of the Act, 
or it must be certified by the State as being a necessary provider of 
health care services to residents in the area. Implementing regulations 
for these provisions were published in an interim final rule with 
comment period in the Federal Register on August 1, 2000 (65 FR 47026) 
and are set forth at Sec. 485.610(b).
    As we indicated in the May 4 proposed rule, recently, concern has 
been expressed that Sec. 485.610(b) does not accurately reflect the 
fact that a facility may satisfy the ``rural location'' requirement 
either by actually being located in a rural area or by being located in 
an urban area but qualifying for treatment as rural under section 
1886(d)(8)(E) of the Act. In addition, we have received questions as to 
whether a potential CAH must meet both the rural location requirement 
and the requirement for location relative to other facilities (or 
certification by the State as a ``necessary provider'').
    To avoid any further confusion, and ensure that our regulations 
reflect the provisions of the law accurately, we proposed to revise 
Sec. 485.610(b) to clarify that a potential CAH must either be actually 
located in a rural area, or be treated as being rural under section 
1886(d)(8)(E) of the Act. In addition, we proposed to place the 
provisions of the existing Sec. 485.610(b)(5) in a newly created 
paragraph (c) entitled, ``Location relative to other facilities or 
necessary provider certification''. We proposed to relocate this 
provision in order to clarify that these criteria are separate from the 
rural location criteria. These changes do not reflect any change in 
policy; they are merely an attempt to improve the clarity of the 
regulations.
    We did not receive any comments on these proposed changes and, 
therefore, are adopting them as final.
8. Other Legislative Changes Affecting CAHs
a. 96-hour Average Length of Stay Standard (Section 403(a) of Public 
Law 106-113 and 42 CFR 485.620(b))
    As stated in the August 1, 2000 interim final rule with comment 
period, prior to the enactment of Public Law 106-113, section 
1820(c)(2)(B)(iii) of the Act limited CAH designation only to 
facilities that provided inpatient care to each patient for a period of 
time not to exceed 96 hours, unless a longer period was required 
because of inclement weather or other emergency conditions, or a peer 
review organization (PRO) or equivalent entity, on request, waived the 
96-hour restriction. Section 403(a) of

[[Page 39926]]

Public Law 106-113 amended section 1820(c)(2)(B)(iii) of the Act to 
require that the 96-hour limit on stays be applied on an annual average 
basis, and to delete the provisions regarding waiver of longer stays. 
Therefore, CAHs will be permitted to keep some individual patients more 
than 96 hours without a waiver request, so long as the facility's 
average length of acute stays in any 12-month cost reporting period is 
not more than 96 hours.
    The effective date of this provision is November 29, 1999.
    In the August 1, 2000 interim final rule with comment period, we 
revised the regulations on conditions of participation for length of 
stay for CAHs at Sec. 485.620(b) to reflect this change.
    Comment: One commenter noted that 96-hour length of stay limitation 
for CAHs clearly contemplates that the facility-wide average length of 
stay be computed as an hourly average, while Medicare cost report 
instructions require inpatient utilization to be reported by days of 
care rather than hours. The commenter expressed concern that if cost 
report data on days of care are converted to an hourly equivalent, this 
might overstate the length of stay for some facilities, since patients 
in the facility for only a few hours might be counted as having been 
inpatients for a full 24 hours. The commenter requested that we provide 
further directions to the fiscal intermediaries on the exact data to be 
used and the precise method to capture the length of stay average.
    Response: We understand the commenter's concern and will ensure 
that any directions to intermediaries and State agencies on determining 
facility-wide average length of stay provide for calculating that 
average accurately. However, no change is needed to the proposed 
regulation and we are adopting it as final.
b. For-Profit Facilities (Section 403(b) of Public Law 106-113 and 42 
CFR 485.610(a))
    As stated in the August 1, 2000 interim final rule with comment 
period, prior to enactment of Public Law 106-113, section 1820(c)(2)(B) 
of the Act allowed only nonprofit or public hospitals to be designated 
as CAHs. Section 403(b) of Public Law 106-113 revises section 
1820(c)(2)(B) of the Act to remove the words ``nonprofit or public'' 
before ``hospitals'', thus enabling for-profit hospitals to qualify for 
CAH status.
    In that interim final rule with comment period, we revised the 
regulations on the conditions of participation related to the status 
and location for CAHs at Sec. 485.610(a) to reflect this change.
    We did not receive any comments on this provision and are adopting 
the revision to Sec. 485.610(a) as final.
c. Closed and Downsized Hospitals (Section 403(c) of Public Law 106-113 
and 42 CFR 485.610(a)(1))
    Under section 1820(c)(2) of the Act, CAH designation was available 
only to facilities currently operating as hospitals. As stated in the 
August 1, 2000 interim final rule with comment period, section 403(c) 
of Public Law 106-113 amended the statute to permit a State to 
designate as a CAH a facility that previously was a hospital but ceased 
operations on or after November 29, 1989 (10 years prior to the 
enactment of Public Law 106-113), if that facility fulfills the 
criteria under section 1820(c)(2)(B) of the Act for CAH designation as 
of the effective date of its designation. The amendment also allows CAH 
designation for facilities that previously had been hospitals, but are 
currently State-licensed health clinics or health centers if they meet 
the revised criteria for designation under section 1820(c)(2) of the 
Act as of the effective date of designation. In the August 1 interim 
final rule with comment period, we revised the CAH criteria for State 
certification under regulations at Sec. 485.610(a)(1) to reflect this 
change.
    Although we received no public comment on the revision to 
Sec. 485.610(a)(1), we have determined that one technical revision to 
Sec. 486.610 is needed. We are making a technical correction to 
paragraph (a)(2) of Sec. 485.610. Currently, that paragraph states that 
a closed facility may qualify for designation as a CAH only if it meets 
applicable criteria for designation under Subpart F of Part 485 ``as of 
November 29, 1999.'' However, under section 1820(c)(2)(C)(ii) of the 
Act, as added by section 403(c)(2) of Public Law 106-113, the facility 
must meet all other applicable requirements for CAH designation by the 
State as of the effective date of its designation as a CAH. Therefore, 
we are revising Sec. 485.610(a)(2) to state that a closed facility may 
qualify for designation as a CAH only if it meets applicable criteria 
for designation under Subpart F of Part 485 as of the effective date of 
that designation.
    In the August 1, 2000 final rule (65 FR 47052), we revised 
Sec. 485.610 to reflect the provisions of section 403(c) of Public Law 
106-113. However, we inadvertently did not make a conforming change to 
Sec. 485.612, which continues to state that the applicant facility must 
be a hospital with a provider agreement to participate in the Medicare 
program at the time it applies for designation as a CAH. To correct 
this oversight and reflect the provisions of section 403(c) in the 
regulations at Sec. 485.612, in the June 13, 2001 interim final rule 
with comment period (66 FR 32183), we revised Sec. 485.612 to state 
that the requirement to have a provider agreement as a hospital at the 
time of application does not apply to recently closed facilities as 
described in Sec. 485.610(a)(2) or to health clinics or health centers 
as described in Sec. 485.610(a)(3).
    We did not receive any comments on this provision and are adopting 
the provisions as final without change.
d. Elimination of Coinsurance for Clinical Diagnostic Laboratory Tests 
Furnished by a CAH (Secs. 410.152 and 413.70))
    As we indicated in both the August 1, 2000 and June 13, 2001 
interim final rules with comment period, under the law in effect before 
the enactment of Public Law 106-113, clinical diagnostic laboratory 
services furnished by a CAH to its outpatients were, like other 
outpatient CAH services, paid for on a reasonable cost basis, subject 
to the Part B deductible and coinsurance provisions. With respect to 
coinsurance, this meant that the beneficiary was responsible for 
payment of 20 percent of the CAH's customary charges for the services 
and the CAH received payment from the Medicare program equal to 80 
percent of its reasonable costs of furnishing the services.
    In the August 1, 2000 interim final rule with comment period (65 FR 
47042), we implemented section 403(e) of Public Law 106-113, which 
amended section 1833(a) of the Act and eliminated the Part B 
coinsurance and deductible for laboratory tests furnished by a CAH on 
an outpatient basis. Thus, CAHs were not permitted to impose a 
deductible or coinsurance charge on the beneficiary for these services. 
Also, in accordance with section 1833(a)(1)(D) and (a)(2)(D), as also 
amended by section 403(e) of Public Law 106-113, Medicare Part B was to 
pay 100 percent of the least of the amount determined under the local 
laboratory fee schedule, the national limitation amount for that test, 
or the amount of the charges billed for the tests.
    The effect of this change was that clinical diagnostic laboratory 
tests furnished by a CAH to its outpatients, were paid for on the same 
basis as clinical diagnostic laboratory tests furnished by full-service 
hospitals to outpatients. Section 403(e)(2) of Public

[[Page 39927]]

Law 106-113 provided that this provision was effective with respect to 
services furnished on or after November 29, 1999. In the August 1, 2000 
interim final rule with comment period, we clarified our policy and 
incorporated the provisions of section 403(e) of Public Law 106-113 in 
Secs. 410.152 and 413.70 of the regulations.
    As we indicated in the June 13, 2001 interim final rule with 
comment period (66 FR 32172), section 201(a) of Public Law 106-554 
amended section 1834(g) of the Act to provide that there will be no 
collection of coinsurance, deductible, copayments, or any other type of 
cost sharing from Medicare beneficiaries with respect to outpatient 
clinical diagnostic laboratory services in a CAH.
    Section 201(a) further provided that payment for these services 
will be made on a reasonable cost basis. Section 201(b) of the Public 
Law 106-554 amended section 1833(a) of the Act by eliminating any 
reference to CAHs receiving payment for outpatient clinical diagnostic 
laboratory services on a fee schedule basis. These amendments are 
effective for services furnished on or after November 29, 1999.
    In the June 13 interim final rule with comment period, we 
incorporated the provisions of section 201 of Public Law 106-554 in 
Sec. 413.70 of the regulations and changed the references cited in 
Sec. 410.152(k)(2). To prevent any misunderstanding of the scope of 
section 201(a), we further revised Sec. 413.70(b)(3)(iii) to clarify 
that payment to a CAH for clinical diagnostic laboratory tests for 
individuals who are not inpatients of the CAH will be made on a 
reasonable cost basis only if the individuals are outpatients of the 
CAH at the time the specimens are collected. Outpatient status will be 
determined under the definition in Sec. 410.2, which provides that an 
``outpatient'' is a person who has not been admitted as an inpatient 
but is registered as an outpatient and receives services (rather than 
supplies alone) from the CAH.
    We indicated that we recognize that CAHs may appropriately function 
as reference laboratories, by performing clinical diagnostic laboratory 
tests on specimens from persons who do not meet the ``outpatient'' 
definition but have the specimens drawn at other locations, such as 
physician offices. Payment for clinical diagnostic laboratory tests for 
these other individuals (that are persons who are not patients of the 
CAH when the specimens are collected) will be made in accordance with 
the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Act.
    Comment: One commenter on the August 1, 2000 interim final rule 
expressed the view that it was Congress' intent to pay CAHs for 
clinical diagnostic laboratory tests for outpatients on the basis of 
reasonable costs, not on the basis of a laboratory fee schedule. The 
commenter suggested that we develop and implement regulations 
permitting reasonable cost payment for these laboratory services.
    Response: As explained earlier, section 201(a) of Public Law 106-
554 subsequently modified the Medicare law to clearly require 
reasonable cost payment for those services and we have implemented that 
provision in the June 13, 2001 interim final rule with comment period 
(which is being finalized in this final rule).
    Comment: Some commenters stated that CAHs frequently perform 
clinical diagnostic laboratory tests on specimens drawn from patients 
at physician offices, nursing homes, and assisted living facilities in 
the community where the CAH is located, and in other rural communities. 
The commenters recommended that reasonable cost payment be made to the 
CAH for these services because, in the commenters' view, doing so would 
help support the provision of health care in these settings.
    Response: As explained above and in the preamble to the June 13 
interim final rule with comment period, section 201(a) of Public Law 
106-554 mandates reasonable cost payment to CAHs for clinical 
diagnostic laboratory tests to CAH patients but does not provide 
similar payment when the CAH functions as a reference laboratory for 
patients who do not come to the CAH but are seen at other locations. 
The statute does not provide for such payment for services to non-CAH 
patients. We believe these laboratory services provided to individuals 
who are not patients of a CAH should be paid for on the same basis as 
such services are generally paid for regardless of the fact that the 
CAH reference laboratory performed the testing, and that payment for 
them on a reasonable cost basis would extend the CAH payment 
methodology far beyond the CAH itself. Thus, we are not adopting the 
commenters' recommendation.
    Comment: One commenter suggested that we not require CAHs to refund 
coinsurance amounts collected from beneficiaries and third-party payers 
for clinical diagnostic laboratory tests furnished to outpatients on or 
after November 29, 1999. The commenter stated that this would be 
appropriate because there has been confusion among some CAHs as to 
their responsibilities in this area, and returning these amounts could 
be burdensome for the CAHs.
    Response: Public Law 106-554 clearly and consistently states that, 
effective November 29, 1999, these services are not subject to 
deductible or coinsurance amounts. Medicare Intermediary Manual 
Transmittal No. 1799 and Medicare Hospital Manual Transmittal No. 757, 
issued in June 2000, reemphasized this point. Therefore, we are not 
making any change in this final rule based on this comment.
e. Assistance With Fee Schedule Payment for Professional Services Under 
All-Inclusive Rate
    Prior to enactment of Public Law 106-113, section 1834(g) of the 
Act provided that the amount of payment for outpatient CAH services 
would be the reasonable costs of the CAH in providing such services. 
However, the reasonable costs of the CAH's services to outpatients 
included only the CAH's costs of providing facility services, and did 
not include any payment for professional services. Physicians and other 
practitioners who furnished professional services to CAH outpatients 
billed the Part B carrier for these services and were paid under the 
physician fee schedule in accordance with the provisions of section 
1848 of the Act.
    In the August 1, 2000 final rule (65 FR 47100), we implemented 
section 403(d) of Public Law 106-113, which amended section 1834(g) of 
the Act to permit the CAH to elect to be paid for its outpatient 
services under an optional method. CAHs making this election would be 
paid amounts equal to the sum of the following costs, less the amount 
that the hospital may charge as described in section 1866(a)(2)(A) of 
the Act (that is, Part A and Part B deductibles and coinsurance 
amounts):
     For facility services, not including any services for 
which payment may be made as outpatient professional services, the 
reasonable costs of the CAH in providing the services; and
     For professional services otherwise included within 
outpatient CAH services, the amounts that would otherwise be paid under 
Medicare if the services were not included as outpatient CAH services.
    Section 403(d) of Public Law 106-113 added section 1834(g)(3) to 
the Act to further specify that payment amounts under this optional 
method are to be determined without regard to the amount of the 
customary or other charge. The amendment made by

[[Page 39928]]

section 403(d) was effective for cost reporting periods beginning on or 
after October 1, 2000.
    In the June 13, 2001 interim final rule with comment period (66 FR 
32172), we implemented section 202 of Public Law 106-554, which amended 
section 1834(g) of the Act to provide that when a CAH elects the option 
to be paid for Medicare outpatient services under the reasonable costs 
for facility services plus fee schedule amounts for professional 
services method, Medicare will pay 115 percent of the amount it would 
otherwise pay for the professional services. This provision is 
effective for items and services furnished on or after July 1, 2001.
    In the June 13 interim final rule with comment period, we revised 
the regulations at Sec. 413.70(b)(3) to reflect the change in the level 
of payment for professional services under the alternative payment 
method for outpatient CAH services.
    Comment: One commenter asked for an explanation of the relationship 
between payment to CAHs for CRNA services to outpatients at 115 percent 
of the amounts that would otherwise be payable under the physician fee 
schedule, and the pass-through of CRNA services costs under 
Sec. 412.113(c) as described in the proposed rule published on May 4, 
2001 (66 FR 22646).
    Response: Under the proposed changes to Secs. 413.70 and 412.113(c) 
that we included in our May 4, 2001 proposed rule, a CAH would be able 
to qualify for the CRNA pass-through (that is, reasonable costs payment 
for its costs of compensating CRNAs for their professional services to 
inpatients and outpatients) on the same basis as a hospital. If a 
particular CAH qualified for the CRNA pass-through and chose to claim 
payment under that method for its CRNA compensation costs, it would be 
paid on a reasonable cost basis for those costs. However, neither the 
CAH nor the individual CRNAs would then be permitted to bill under the 
physician fee schedule for any CRNA services to CAH patients. In 
particular, if the CAH chose the elective (115 percent) method of 
payment for professional services to CAH outpatients, its billings for 
those services could not include any amounts for CRNA services.
    If a CAH was not qualified for the CRNA pass-through (because, for 
example, it furnished 500 or more surgical procedures requiring 
anesthesia per year), or was qualified but chose not to claim payment 
under the pass-through method, but did choose payment for professional 
services to CAH outpatients under the elective (115 percent) method, 
payment for CRNA services to outpatients would be made under the 
elective (115 percent) method. Under these circumstances, the CAH could 
not claim any CRNA compensation costs for the services on its cost 
report.
    Comment: One commenter asked whether payment under the optional 
method described in Sec. 413.70(b)(3) is available for all professional 
services to CAH outpatients in CAH space, including professional 
services the commenter described as ``clinic visits''.
    Response: The optional method applies to professional services 
otherwise included within outpatient CAH services provided to CAH 
outpatients. Outpatient CAH services are those medical and other 
services furnished by a CAH on an outpatient basis. Services that are 
not otherwise provided in a CAH on an outpatient basis, such as 
services provided by a home health agency owned or operated by a CAH, 
are paid under the payment rules applicable to the specific provider or 
supplier type and cannot be made under the optional method of payment 
for outpatient CAH services.
    Comment: One commenter asked whether physicians and other 
practitioners who would otherwise be permitted to bill the Medicare 
Part B carrier for their professional services provided to CAH patients 
could reassign their Part B billing rights for those services to the 
CAH under the existing reassignment rules.
    Response: The commenter is correct in understanding that 
practitioners may reassign their billing rights for professional 
services provided to CAH patients under applicable reassignment rules. 
Such reassignment would be needed to help ensure that there is not 
duplicate billing for those services.
    Comment: One commenter stated that our current manual instructions 
require all professional services to the outpatients of a particular 
CAH to be billed under either the method in Sec. 413.70(b)(2) 
(reasonable costs for facility services, with billing by the 
practitioner to the carrier for professional services) or the optional 
method in Sec. 413.70(b)(3) (reasonable costs for facility services 
with billing by the CAH for professional services). The commenter asked 
whether a CAH would be permitted to elect the Sec. 413.70(b)(3) method 
on a practitioner-by-practitioner basis, so that some practitioners' 
services would be billed by the CAH while others would be billed by the 
practitioner.
    Response: We appreciate the commenter's request and note that we 
have already addressed this issue in our regulations. Specifically, the 
regulations at Sec. 413.70(b)(3)(i) state that once a CAH elects the 
optional method for payment of outpatient CAH services for a cost 
reporting period, the optional payment method remains in effect for all 
of that period and applies to all outpatient CAH services furnished to 
outpatients of the CAH during that period.
    Comment: Some commenters noted that section 202 of Pubic Law 106-
554 makes the 115 percent payment option for professional services to 
CAH outpatients available for services furnished on or after July 1, 
2001. However, the commenters also stated that our program instructions 
state that the systems changes needed to permit payment at that level 
will not be available before October 1, 2001. The commenters asked for 
confirmation that the payment at the 115 percent level for services 
furnished on or afterJuly 1, 2001, will be made available to CAHs 
electing payment under the optional method, and suggested various 
alternatives, including possible retroactive payment adjustments by the 
intermediary, by which this could be accomplished.
    Response: We appreciate the commenters' suggestions. We will 
continue to explore all feasible approaches to ensuring that payment is 
made in accordance with statutory requirements and will consider the 
various suggestions made by the commenter as we work to achieve this 
result.
f. Conforming Change--Conditions of Participation Relating to 
Compliance With Hospital Requirements at Time of Application for CAH 
Designation (Sec. 485.612)
    Under the law in effect prior to enactment of Public Law 106-113, 
CAH status was available to facilities only if they were hospitals at 
the time of their application for designation as CAHs. This requirement 
was implemented through regulations at Sec. 485.610 (Condition of 
participation: Status and limitations) and Sec. 485.612 (Condition of 
Participation: Compliance with hospital requirements at time of 
application). As we previously noted, section 403(c) of Public Law 106-
113 added subparagraphs (C) and (D) to section 1820(c)(2) of the Act to 
specify that recently closed facilities and facilities that had 
downsized from hospital status to being a clinic or health center would 
also be eligible to apply for CAH designation.
    As noted earlier, in the August 1, 2000 final rule(65 FR 47052), we 
revised our regulations at Sec. 485.610 to reflect the provisions of 
section 403(c) of the

[[Page 39929]]

Public Law 106-113. However, we inadvertently did not make a conforming 
change to Sec. 485.612, which continues to state that the applicant 
facility must be a hospital with a provider agreement to participate in 
the Medicare program at the time it applies for designation as a CAH. 
To correct this oversight and reflect the provisions of section 403(c) 
in the regulations at Sec. 485.612, in the June 13, 2001 interim final 
rule with comment period(66 FR 32183), we revised Sec. 485.612 to state 
that the requirement to have a provider agreement as a hospital at the 
time of application does not apply to recently closed facilities as 
described in Sec. 485.610(a)(2) or to health clinics or health centers 
as described in Sec. 485.610(a)(3).
    We did not receive any comments on this regulation revision and are 
adopting it as final.
g. Participation in Swing-Bed Program (Section 403(f) of Public Law 
106-113)
    Section 403(f) of Public Law 106-113, entitled ``Improvements in 
the Critical Access Hospital Program,'' included a provision on swing-
bed agreements. In the August 1, 2000 interim final rule with comment 
period, we indicated that since our existing regulations at 
Sec. 485.645 already provide for swing beds in CAHs, we were not making 
any changes to our regulations based on this provision.
    We did not receive any comments on this provison and are adopting 
our interim decision not to make any changes to our regulations as 
final.

C. Hospital Swing Bed Program

    In the August 1, 2000 interim final rule with comment period (65 FR 
47042), we indicated that section 408(a) of Public Law 106-113 amended 
section 1883(b) of the Act to remove the provision that in order for a 
hospital to enter into an agreement to provide Medicare post-hospital 
extended care services, the hospital had to be granted a certificate of 
need for the provision of long-term care services from the State health 
planning and development agency (designated under section 1521 of the 
Public Health Service Act) for the State in which the hospital is 
located. Section 408(b) of Public Law 106-113 amended section 1883(d) 
of the Act to remove the provisions under paragraphs (d)(2) and (d)(3) 
that placed restrictions on lengths of stays in hospitals with more 
than 49 beds for post-hospital extended care services. These provisions 
are effective on the first day after the expiration of the transition 
period under section 1888(e)(2)(E) of the Act for payment for covered 
skilled nursing facility (SNF) services under the Medicare program; 
that is, at the end of the transition period for the SNF prospective 
payments system that began with the facility's first cost reporting 
period beginning on or after July 1, 1998 and extend through the end of 
the facility's third cost reporting period after this date.
    The Medicare regulations that implemented the provision of section 
1883(b) of the Act are located at Sec. 482.66(a)(3). The regulations 
that implemented the provisions of sections 1883(d)(2) and (d)(3) of 
the Act are located at Secs. 482.66(a)(6) and (a)(7). As a result of 
the changes made by section 408(a) and (b) of Public Law 106-113, in 
the August 1, 2000 interim final rule with comment period, we removed 
Secs. 482.66(a)(3), (a)(6), and (a)(7). (Existing paragraphs (a)(4) and 
(a)(5) were redesignated as (a)(3) and (a)(4), respectively, as a 
result of the removal of existing paragraph (a)(3).)
    We did not receive any comments on our revisions to the regulations 
in the interim final rule with comment period and are adopting them as 
final.

VII. MedPAC Recommendations

    On March 1, 2001, the Medicare Payment Advisory Commission (MedPAC) 
issued its annual report to Congress, including several recommendations 
related to the inpatient operating payment system. Those related to the 
inpatient prospective payment systems included: accounting for new 
technology in hospital prospective payment systems, implementation of 
an occupational-mix adjusted wage index for FY 2005, financial 
performance and inpatient payment issues, and elimination of the 
weighting factors for direct GME for specialties with training beyond 
the initial residency period. In the May 4, 2001 proposed rule, we 
responded to these recommendations (66 FR 22713-22714).
    In addition, we addressed Recommendation 5A concerning the update 
factor for inpatient hospital operating costs and for hospitals and 
hospital distinct-part units excluded from the prospective payment 
system in Appendix D to the proposed rule (and in Appendix C of this 
final rule).

A. Accounting for New Technology in Hospital Prospective Payment 
Systems (Recommendations 3D and 3E)

    Recommendation 3D: For the inpatient payment system, the Secretary 
should develop formalized procedures for expeditiously assigning codes, 
updating relative weights, and investigating the need for patient 
classification changes to recognize the costs of new and substantially 
improved technologies.
    Response: Section 533 of Public Law 106-554 directs the Secretary 
to develop a mechanism for ensuring adequate payment under the hospital 
inpatient prospective payment system for new medical services and 
technologies, and to report to Congress on ways to more expeditiously 
incorporate new services and technologies into that system. The 
discussion relating to new medical services and technologies was 
included in section II.D. of the May 4, 2001 proposed rule.
    MedPAC states that a more formal system for assigning codes and 
investigating the need for DRG changes would have enabled the current 
system to more adequately respond to new technology. Although we 
believe the current process for assigning new codes has the advantage 
of being well-understood, we proposed a new process in the May 4 
proposed rule. We will be finalizing this process in a separate final 
rule.
    Recommendation 3E: Additional payments in the inpatient payment 
system should be limited to new or substantially improved technologies 
that add significantly to the cost of care in a diagnosis related group 
and should be made on a budget-neutral basis.
    Response: Section 533 of Public Law 106-554 directed the Secretary 
to establish a mechanism by October 1, 2001. We will be finalizing this 
process in a separate final rule.

B. Occupational-Mix Adjusted Wage Index for FY 2005 (Recommendation 4)

    Recommendation: To implement an occupation-mix adjusted wage index 
in FY 2005, the Secretary should collect data on wage rates by 
occupation in the fiscal year 2002 Medicare cost reports. Hospital-
specific wage rates for each occupation should be supplemented by data 
on the mix of occupations for each provider type. The Secretary also 
should continue to improve the accuracy of the wage index by 
investigating differences in wages across areas for each type of 
provider and in the substitution of one occupation for another.
    Response: In the May 4 proposed rule, we proposed to collect 
occupational mix data from hospitals through a supplemental survey to 
the cost report for cost reporting periods beginning during FY 2001. A 
more complete discussion of the proposed methodology in the May 4 
proposed rule (66 FR 22674) and the public comments we received and our 
responses can be found in section III.C.3. of this final rule.

[[Page 39930]]

C. Financial Performance and Inpatient Payment Issues (Recommendations 
5B, 5C, and 5D)

    Recommendation 5B: In collecting sample patient-level data, CMS 
should seek to balance the goals of minimizing payment errors and 
furthering understanding of the effects of coding on case-mix change.
    Response: The sample data referred to by MedPAC is the Payment 
Error Prevention Program (PEPP) Surveillance Sample. These data are 
collected to monitor the payment error rate for Medicare inpatient 
prospective payment system services and provide outcome data to measure 
PROs' performance in reducing payment errors in their respective 
States. This information can be appropriately weighted to reflect the 
true distribution of DRGs nationally. The sample data supplant the DRG 
validation sample that MedPAC used in its original 1996 through 1998 
estimates. The current PEPP Surveillance Sample doubles the size of the 
earlier DRG validation sample. It is comprised of approximately 60,000 
cases per year. We believe this is a sufficient number of cases to both 
monitor case-mix index changes and PRO performance on payment error 
reduction.
    Recommendation 5C: Although the Benefits Improvement and Protection 
Act of 2000 improved the equity of the hospital disproportionate share 
adjustment, Congress still needs to reform this adjustment by:
     Including the costs of all poor patients in calculating 
low-income shares used to distribute disproportionate share payments; 
and
     Using the same formula to distribute payments to all 
hospitals covered by prospective payment.
    Response: CMS is participating in a Medicare Technical Advisory 
Group workgroup concerning technical issues related to the collection 
of uncompensated care data relative to the Medicare disproportionate 
share formula. A worksheet and instructions to collect these data will 
be sent out for prior consultation this summer for revisions to the 
cost reports applicable for cost reporting periods beginning on or 
after October 1, 2001.
    Recommendation 5E: The Congress should protect urban hospitals from 
the adverse effect of nearby hospitals being reclassified to areas with 
higher wage indexes by computing each area's wage index as if none of 
the hospitals located in the area had been reassigned.
    Response: In the May 4 proposed rule as in this final rule, CMS 
includes the wage data for a reclassified hospital in both the area to 
which it is reclassified and the area where the hospital is physically 
located. We agree with MedPAC and believe that this will provide 
consistency and predictability in hospital reclassification and wage 
indices.

D. Specialties With Training Beyond the Initial Residency Period 
(Recommendation 10)

    Recommendation: The Congress should eliminate the weighting factors 
that currently determine Medicare's direct graduate medical education 
payments and count all residencies equally through completion of 
residents' first specialty or combined program and subspecialty if one 
is pursued. Residents training longer than the minimum number of years 
required for board eligibility in a specialty, combined program, or 
subspecialty should not be included in hospitals' direct graduate 
medical education resident counts. These policy changes should be 
implemented in a budget-neutral manner through adjustments to the per 
resident payment amounts.
    Response: Currently, Medicare payments to hospitals for direct GME 
is dependent, in part, on the initial residency period of the 
residents. Generally, the initial residency period is defined at 
Sec. 413.86(g)(1) as the minimum number of years required for board 
eligibility, not to exceed 5 years. For purposes of determining the 
direct GME payment, residents are weighted at 1.0 FTE within the 
initial residency period, and at .5 FTE beyond the initial residency 
period. The limitation on the initial residency period was designed by 
Congress to limit full Medicare direct GME payment to the time required 
to train in a single specialty.
    MedPAC states that Medicare's current direct GME payment policy of 
limiting full funding to the first specialty in which a resident trains 
provides a disincentive for hospitals to offer training in 
subspecialties or combined programs and, therefore, may influence 
hospitals' decisions on the types of residents that they train. MedPAC 
believes that Medicare should not influence workforce policy and 
recommends that the disincentive be removed to make Medicare payments 
policies neutral with regard to programs with prerequisites, 
subspecialties, and combined programs. Accordingly, MedPAC recommends 
that Congress eliminate the weighting factors associated with direct 
GME payment so that all residents would be counted for full direct GME 
payment through the completion of their first specialty, combined 
program, or subspecialty. Residents training beyond the minimum number 
of years required for board eligibility in a specialty, combined 
program, or subspecialty should not be counted for purposes of the 
direct GME payment.
    MedPAC also believes that eliminating the weighting factors could 
potentially increase Medicare's direct GME payments by approximately 5 
to 8 percent. Therefore, MedPAC recommends that hospitals' per resident 
amounts (PRAs), which are used to calculate the direct GME payment, be 
reduced so that this change can be implemented, to the extent possible, 
in a budget-neutral manner. MedPAC explains that, although further 
research is needed, it appears that hospitals with substantial 
subspecialty training (that is, at least 15 percent of the resident 
mix) would likely see a small net increase in payments, despite the 
reduction to the PRAs, while hospitals that do not have subspecialty 
training would likely see a small decrease in payments.
    In response to MedPAC's recommendation, we question MedPAC's 
estimate that eliminating the weighting factors could increase Medicare 
direct GME payments by only 5 to 8 percent. We believe that 
subspecialty training constitutes a significant portion of all GME 
programs, and, consequently, the elimination of the weighting factors 
could potentially increase payments by far more than 8 percent. If 
budget neutrality is to be maintained, this could mean that the 
attendant reductions to the PRAs could be much greater than MedPAC 
might assume. For those teaching hospitals that have substantial 
subspecialty training, there is no guarantee that the decreases in the 
PRAs will be offset by the increases in the direct GME payments due to 
the elimination of the weighting factors.
    While the recommendation would remove the existing disincentive for 
training in subspecialties, we believe the reductions to the PRAs, 
whether they are minimal or more significant, will be far more 
detrimental to the smaller teaching hospitals that have little or no 
subspecialty training. Many of these hospitals provide care to 
beneficiaries in rural, underserved areas and in nonhospital settings. 
We believe these conditions may discourage the expansion of residency 
training in these areas. It may be inappropriate to limit the direct 
GME funding to such hospitals, considering Congress' initiatives to 
encourage residency training in rural, underserved areas and in 
nonhospital settings. We also are unclear as to how MedPAC would 
implement the proposed reduction to the PRAs. MedPAC did not explain in

[[Page 39931]]

its recommendation how it would propose to do this.

VIII. Other Required Information

A. Requests for Data from the Public

    In order to respond promptly to public requests for data related to 
the prospective payment system, we have established a process under 
which commenters can gain access to raw data on an expedited basis. 
Generally, the data are available in computer tape or cartridge format; 
however, some files are available on diskette as well as on the 
Internet at http://www.hcfa.gov/stats/pubfiles.html. In our May 4, 2001 
proposed rule, we published a list of data files that are available for 
purchase (66 FR 22714-22716).

B. Information Collection Requirements

    Under the Paperwork Reduction Act of 1995, we are required to 
provide 60-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 requires that we solicit comment on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    In the May 4, 2001 proposed rule, we solicited public comments on 
each of these issues for the following sections that contain 
information collection requirements.

Section 412.230(e)(2)(ii)  Criteria for an Individual Hospital Seeking 
Redesignation to Another Rural Area or an Urban Area; 
Sec. 412.232(d)(2)(ii) Criteria for All Hospitals in a Rural County 
Seeking Urban Redesignation; Sec. 412.235 Criteria for All Hospitals in 
a State Seeking a Statewide Wage Index; and Revised Sec. 412.273 
Withdrawing an Application or Terminating an Approved 3-Year 
Reclassification

    Proposed Secs. 412.230(e)(2)(ii) and 412.232(d)(2)(ii) specified 
that, for hospital-specific data for wage index changes for 
redesignations effective beginning FY 2003, the hospital must provide a 
3-year average of its average hourly wages using data from the CMS 
hospital wage survey used to construct the wage index in effect for 
prospective payment purposes. For other data, the hospital must provide 
a weighted 3-year average of the average hourly wage in the area in 
which the hospital is located and a weighted 3-year average of the 
average hourly wage in the area to which the hospital seeks 
reclassification. Proposed new Sec. 412.235 specifies that in order for 
all prospective payment system hospitals in a State to use a statewide 
wage index, the hospitals as a group must submit an application to the 
MGCRB for a decision for reclassifications for wage index purposes. The 
proposed changes to Sec. 412.273 incorporated proposed revised 
procedures for hospitals that request withdraw of their wage index 
application or termination of their wage index reclassification.
    The final versions of these proposed changes, discussed in detail 
in section IV.G. of this final rule, implement sections 304 (a) and (b) 
of Public Law 106-554.
    The information collection requirements associated with a 
hospital's application to the MGCRB for geographic reclassifications, 
including reclassifications for wage index purposes and the required 
submittal of wage data, that are codified in Part 412 are currently 
approved by OMB under OMB Approval Number 0938-0573, with an expiration 
date of September 30, 2002.

Section 412.348(g)(9)  Exception Payments

    As discussed in section V. of the May 4 proposed rule, Medicare 
makes special exceptions payments for capital-related costs through the 
10th year beyond the end of the capital prospective payment system 
transition period for eligible hospitals that complete a project that 
meets certain requirements specified in Sec. 412.348. In order to 
assist our fiscal intermediaries in determining the end of the 10-year 
period in which an eligible hospital will no longer be entitled to 
receive special exception payments, we proposed to add a new 
Sec. 412.348(g)(9) to require that hospitals eligible for special 
exception payments under Sec. 412.348(g) submit documentation to the 
intermediary indicating the completion date of their project (the date 
the project was put in use for patient care) that meets the project 
need and project size requirements outlined in Secs. 412.348 (g)(2) 
through (g)(5). We proposed that, in order for an eligible hospital to 
receive special exception payments, this documentation would have to be 
submitted in writing to the intermediary by the later of October 1, 
2001, or within 3 months of the end of the hospital's last cost 
reporting period beginning before October 1, 2001, during which a 
qualifying project was completed.
    Because this provision is expected to affect less than 10 hospitals 
on an annual basis, this requirement is not subject to the PRA as 
stipulated under 5 CFR 1320.3(c).
    In the August 1, 2000 interim final rule with comment period, we 
solicited public comments on each of these issues for the following 
section that contains information collection requirements.

Section 412.103(b)  Special treatment: Hospitals Located in Urban Areas 
and That Apply for Reclassification as Rural; Application Requirements

    Section 412.103(b) specifies that a facility seeking 
reclassification under sections 401 (a) or (b) of Public Law 106-113 
must apply in writing to the CMS Regional Office and include 
documentation of the criteria on which its request is based. The 
application must be mailed; facsimile or other electronic means are not 
acceptable.
    The hospital's application must include a copy of the State law or 
regulation or other authoritative document verifying that the 
requesting hospital is situated in an area determined to be rural by 
the State or the hospital is considered to be a rural hospital.
    We estimate that it will take each hospital approximately 30 
minutes to complete the application process. We estimate that 
additional time would be needed to collect the required documentation. 
This recordkeeping should take no more than approximately 2 hours. 
Therefore, the paperwork burden associated with the reclassification 
process would add up to an additional 2\1/2\ hours per hospital that 
request reclassification under section 401 of Public Law 106-113.
    This information collection requirement has been submitted to the 
Office of Management and Budget for approval and is not effective until 
OMB approves it.
    If you have any comments on any of these information collection and 
recordkeeping requirements, please mail one original and three copies 
within 30 days of the publication date directly to the following:

Centers for Medicare & Medicaid Services, Office of Information 
Services, Information Technology Investment Management Group,Division 
of HCFA Enterprise Standards,Room N2-14-26,7500 Security 
Boulevard,Baltimore, MD

[[Page 39932]]

21244-1850,Attn: John Burke, CMS-1158/31/78-F.
        And
Office of Information and Regulatory Affairs, Room 10235, New Executive 
Office Building,Washington, DC 20503,Attn: Allison Eydt, HCFA Desk 
Officer.

List of Subjects

42 CFR Part 405

    Administrative practice and procedure, Health facilities, Health 
professions, Kidney diseases, Medicare, Reporting and recordkeeping 
requirements, Rural areas,X-rays.

42 CFR Part 410

    Health facilities, Health professions, Kidney diseases, 
Laboratories, Medicare, Reporting and recordingkeeping requirements, 
Rural areas, X-rays.

42 CFR Part 412

    Administrative practice and procedure, Health facilities, Medicare, 
Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

    Health facilities, Kidney diseases, Medicare, Puerto Rico, 
Reporting and recordkeeping requirements.

42 CFR Part 482

    Grant program-health, Hospitals, Medicaid, Medicare, Reporting and 
recordkeeping requirements.

42 CFR Part 485

    Grant programs-health, Health facilities, Medicaid, Medicare, 
Reporting and recordkeeping requirements.

42 CFR Part 486

    Health professions, Medicare, Organ procurement, X-rays.


    Accordingly, 42 CFR chapter IV is amended as follows:
    I. The interim final rule with comment period amending 42 CFR Parts 
410, 412, 413, 482, and 485 which was published at 65 FR 47026 on 
August 1, 2000, is adopted as a final rule with the following changes:

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR 
END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT 
RATES FOR SKILLED NURSING FACILITIES

    1. The authority citation for Part 413 is revised to read as 
follows:

    Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and 
(n), 1871, 1881, 1883, and 1886 of the Social Security Act (42 
U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 
1395hh, 1395rr, 1395tt, and 1395ww).


    2. Section 413.86 is amended by:
    a. Revising the first sentence of the introductory text of 
paragraphs (g)(11)(i).
    b. Revising the first sentence of the introductory text of 
paragraph (g)(11)(ii).
    c. Revising paragraph (g)(11)(v)(C).


Sec. 413.86  Direct graduate medical education payments.

* * * * *
    (g) * * *
    (11) * * *
    (i) If an urban hospital rotates residents to a separately 
accredited rural track program at a rural hospital(s) for two-thirds of 
the duration of the program, the urban hospital may include those 
residents in its FTE count for the time the rural track residents spend 
at the urban hospital. * * *
    (ii) If an urban hospital rotates residents to a separately 
accredited rural track program at a rural nonhospital site(s) for two-
thirds of the duration of the program, the urban hospital may include 
those residents in its FTE count, subject to the requirements under 
paragraph (f)(4) of this section. * * *
    (v) * * *
    (C) All residents that are included by the hospital as part of its 
rural track FTE count (not to exceed its rural track FTE limitation) 
must train in the rural area. However, where a resident begins to train 
in the rural track program at the urban hospital but leaves the program 
before completing the total required portion of training in the rural 
area, the urban hospital may count the time the resident trained in the 
urban hospital if another resident fills the vacated FTE slot and 
completes the training in the rural portion of the rural track program. 
An urban hospital may not receive graduate medical education payment 
for the time the resident trained at the urban hospital if another 
resident fills the vacated FTE slot and first begins to train at the 
urban hospital.
* * * * *

    II. The interim final rule with comment period amending 42 CFR 
Parts 410, 412, 413, and 485 which was published at 66 FR 32172 on June 
13, 2001, is adopted as a final rule with the following changes:

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    1. The authority citation for Part 412 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


    2. Section 412.108 is amended by revising paragraph (b) to read as 
follows:


Sec. 412.108  Special treatment; Medicare-dependent, small rural 
hospitals.

* * * * *
    (b) Classification procedures. The fiscal intermediary determines 
whether a hospital meets the criterion in paragraph (a) of this 
section. A hospital must notify its fiscal intermediary to be 
considered for MDH status based on the criterion under paragraph 
(a)(1)(iii)(C) of this section. Any hospital that believes it meets 
this criterion to qualify as an MDH, based on at least two of the three 
most recent audited cost reporting periods, must submit a written 
request to its intermediary. The intermediary will make its 
determination and notify the hospital within 90 days from the date that 
it receives the hospital's request and all of the required 
documentation. If a hospital disagrees with an intermediary's 
determination, it should notify its intermediary and submit 
documentable evidence that it meets the criteria. The intermediary 
determination is subject to review under subpart R of part 405 of this 
chapter. MDH status is effective 30 days after the date of written 
notification of approval. The time required by the intermediary to 
review the request is considered good cause for granting an extension 
of the time limit for the hospital to apply for such a review.
* * * * *

    III. For the reasons set forth in the preamble to this final rule, 
42 CFR Chapter IV is amended as set forth below:

PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED

    A. Part 405 is amended as set forth below:
    1. The authority citation for Part 405 continues to read as 
follows:

    Authority: Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and 
1886(k) of the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a), 
1395hh, 1395kk, 1395rr, and 1395ww(k), and sec. 353 of the Public 
Health Service Act (42 U.S.C. 263a).


    2. In Sec. 405.2468, paragraph (f)(6)(ii) is republished and 
paragraph (f)(6)(ii)(D) is revised to read as follows.


Sec. 405.2468  Allowable costs.

* * * * *
    (f) Graduate medical education. * * *
    (6) * * *

[[Page 39933]]

    (ii) The following costs are not allowable graduate medical 
education costs--
* * * * *
    (D) The costs associated with activities described in 
Sec. 413.85(h) of this chapter.
* * * * *

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    B. Part 412 is amended as follows:
    1. The authority citation for Part 412 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


    2. Section Sec. 412.2 is amended as follows:
    a. The introductory text of paragraph (e) is republished.
    b. Paragraph (e)(4) is revised.


Sec. 412.2  Basis of payment.

* * * * *
    (e) Excluded costs. The following inpatient hospital costs are 
excluded from the prospective payment amounts and are paid on a 
reasonable cost basis:
* * * * *
    (4) The acquisition costs of hearts, kidneys, livers, lungs, 
pancreas, and intestines (or multivisceral organs) incurred by approved 
transplantation centers.
* * * * *

    3. Section 412.23 is amended by adding a new paragraph (i) to read 
as follows:


Sec. 412.23  Excluded hospitals: Classifications.

* * * * *
    (i) Changes in classification of hospitals. For purposes of 
exclusions from the prospective payment system, the classification of a 
hospital is effective for the hospital's entire cost reporting period. 
Any changes in the classification of a hospital are made only at the 
start of a cost reporting period.

    4. Section 412.25 is amended by adding a new paragraph (f) to read 
as follows:


Sec. 412.25  Excluded hospital units: Common requirements.

* * * * *
    (f) Changes in classification of hospital units. For purposes of 
exclusions from the prospective payment system under this section, the 
classification of a hospital unit is effective for the unit's entire 
cost reporting period. Any changes in the classification of a hospital 
unit is made only at the start of a cost reporting period.

    5. Section 412.63 is amended by revising paragraphs (t) and (u) to 
read as follows:


Sec. 412.63  Federal rates for inpatient operating costs for fiscal 
years after Federal fiscal year 1984.

* * * * *
    (t) Applicable percentage change for fiscal years 2002 and 2003. 
The applicable percentage change for fiscal years 2002 and 2003 is the 
percentage increase in the market basket index for prospective payment 
hospitals (as defined in Sec. 413.40(a) of this subchapter) minus 0.55 
percentage points for hospitals in all areas.
    (u) Applicable percentage change for fiscal year 2004 and for 
subsequent fiscal years. The applicable percentage change for fiscal 
year 2004 and for subsequent years is the percentage increase in the 
market basket index for prospective payment hospitals (as defined in 
Sec. 413.40(a) of this subchapter) for hospitals in all areas.
* * * * *
    6. Section 412.92 is amended as follows:
    a. Paragraph (b)(1)(iii)(A) is amended by revising the phrase ``50 
mile radius'' to read ``35 mile radius''.
    b. Paragraph (c)(1) is revised.


Sec. 412.92  Special treatment: Sole community hospitals.

* * * * *
    (c) Terminology. * * *
    (1) The term miles means the shortest distance in miles measured 
over improved roads. An improved road for this purpose is any road that 
is maintained by a local, State, or Federal government entity and is 
available for use by the general public. An improved road includes the 
paved surface up to the front entrance of the hospital.
* * * * *


Sec. 412.105  Special treatment: Hospitals that incur indirect costs 
for graduate medical education programs.

    7. Section 412.105 is amended as follows:
    a. The introductory text of paragraph (a) is republished.
    b. Paragraph (a)(1) is revised.
    c. Paragraph (d)(3)(vi) is revised.
    d. A new paragraph (d)(3)(vii) is added.
    e. Paragraph (f)(1)(ii)(C) is revised.
    f. Paragraph (f)(1)(iii) is revised.
    g. Paragraph (f)(1)(v) is amended by adding five sentences at the 
end.
    h. In paragraph (f)(1)(vii), the reference to ``Sec. 413.86(g)(9)'' 
is removed and ``Sec. 413.86(g)(12)'' is added in its place.
    i. Paragraph (f)(1)(ix) is revised.


Sec. 412.105  Special treatment: Hospitals that incur indirect costs 
for graduate medical education programs.

* * * * *
    (a) Basic data. CMS determines the following for each hospital:
    (1) The hospital's ratio of full-time equivalent residents, except 
as limited under paragraph (f) of this section, to the number of beds 
(as determined under paragraph (b) of this section). Except for the 
special circumstances for affiliated groups and new programs described 
in paragraphs (f)(1)(vi) and (f)(1)(vii) of this section, for a 
hospital's cost reporting periods beginning on or after October 1, 
1997, this ratio may not exceed the ratio for the hospital's most 
recent prior cost reporting period after accounting for the cap on the 
number of allopathic and osteopathic full-time equivalent residents as 
described in paragraph (f)(1)(iv) of this section, and adding to the 
capped numerator any dental and podiatric full-time equivalent 
residents. The exception for new programs described in paragraph 
(f)(1)(vii) of this section applies to each new program individually 
for which the full-time equivalent cap may be adjusted based on the 
period of years equal to the minimum accredited length of each new 
program.
* * * * *
    (d) Determination of education adjustment factor. * * *
* * * * *
    (3) * * *
    (vi) For discharges occurring during fiscal year 2002, 1.6.
    (vii) For discharges occurring on or after October 1, 2002, 1.35.
* * * * *
    (f) Determining the total number of full-time equivalent residents 
for cost reporting periods beginning on or after July 1, 1991. * * *
    (1) * * *
    (ii) * * *
    (C) Effective for discharges occurring on or after October 1, 1997, 
the time spent by a resident in a nonhospital setting in patient care 
activities under an approved medical residency training program is 
counted towards the determination of full-time equivalency if the 
criteria set forth in Sec. 413.86(f)(3) or Sec. 413.86(f)(4) of this 
subchapter, as applicable, are met.
    (iii)(A) Full-time equivalent status is based on the total time 
necessary to fill a residency slot. No individual may be counted as 
more than one full-time equivalent. If a resident is assigned to

[[Page 39934]]

more than one hospital, the resident counts as a partial full-time 
equivalent based on the proportion of time worked in any of the areas 
of the hospital listed in paragraph (f)(1)(ii) of this section, to the 
total time worked by the resident. A part-time resident or one working 
in an area of the hospital other than those listed under paragraph 
(f)(1)(ii) of this section (such as a freestanding family practice 
center or an excluded hospital unit) would be counted as a partial 
full-time equivalent based on the proportion of time assigned to an 
area of the hospital listed in paragraph (f)(l)(ii) of this section, 
compared to the total time necessary to fill a full-time residency 
slot.
    (B) The time spent by a resident in research that is not associated 
with the treatment or diagnosis of a particular patient is not 
countable.
* * * * *
    (v) * * * If a hospital qualified for an adjustment to the limit 
established under paragraph (f)(1)(iv) of this section for new medical 
residency programs created under paragraph (f)(1)(vii) of this section, 
the count of residents participating in new medical residency training 
programs above the number included in the hospital's FTE count for the 
cost reporting period ending during calendar year 1996 is added after 
applying the averaging rules in this paragraph (f)(l)(v) for a period 
of years. Residents participating in new medical residency training 
programs are included in the hospital's FTE count before applying the 
averaging rules after the period of years has expired. For purposes of 
this paragraph, for each new program started, the period of years 
equals the minimum accredited length for each new program. The period 
of years for each new program begins when the first resident begins 
training in each new program. Subject to the provisions of paragraph 
(f)(1)(ix) of this section, FTE residents that are displaced by the 
closure of either another hospital or another hospital's program are 
added to the FTE count after applying the averaging rules in this 
paragraph (f)(l)(v) for the receiving hospital for the duration of time 
that the displaced residents are training at the receiving hospital.
* * * * *
    (ix) A hospital may receive a temporary adjustment to its full-time 
equivalent cap to reflect residents added because of another hospital's 
closure if the hospital meets the criteria specified in 
Secs. 413.86(g)(8)(i) and (g)(8)(ii) of this subchapter. If a hospital 
that closes its residency training program agrees to temporarily reduce 
its FTE cap according to the criteria specified in 
Secs. 413.86(g)(8)(i) and (g)(8)(iii)(B) of this subchapter, another 
hospital(s) may receive a temporary adjustment to its FTE cap to 
reflect residents added because of the closure of the residency 
training program if the criteria specified in Secs. 413.86(g)(8)(i) and 
(g)(8)(iii)(A) of this subchapter are met.
* * * * *

    8. Section 412.106 is amended by revising the heading of paragraph 
(e) and paragraph (e)(5) to read as follows:


Sec. 412.106  Special treatment: Hospitals that serve a 
disproportionate share of low-income patients.

* * * * *
    (e) Reduction in payments beginning FY 1998. * * *
    (5) For FY 2002, 3 percent.
* * * * *


Sec. 412.113  [Amended]

    9. In Sec. 412.113(c), including the heading for paragraph (c), the 
term ``hospital'', wherever it appears, is revised to read ``hospital 
or CAH'' (16 times).

    10. Section 412.230 is amended by a new paragraph (a)(5)(v) and 
revising paragraph (e)(2) to read as follows:


Sec. 412.230  Criteria for an individual hospital seeking redesignation 
to another rural area or an urban area.

    (a) * * *
    (5) Limitations on redesignation. * * *
    (v) Beginning with wage index reclassification applications for FY 
2003, if a hospital is already reclassified to a given geographic area 
for wage index purposes for a 3-year period, and submits an application 
for reclassification to the same area for either the second or third 
year of the 3-year period, that application will not be approved.
* * * * *
    (e) Use of urban or other rural area's wage index. * * *
* * * * *
    (2) Appropriate wage data. For a wage index change, the hospital 
must submit appropriate wage data as follows:
    (i) For redesignations effective through FY 2002:
    (A) For hospital-specific data, the hospital must provide data from 
the CMS hospital wage survey used to construct the wage index in effect 
for prospective payment purposes during the fiscal year prior to the 
fiscal year for which the hospital requests reclassification.
    (B) For data for other hospitals, the hospital must provide data 
concerning the average hourly wage in the area in which the hospital is 
located and the average hourly wage in the area to which the hospital 
seeks reclassification. The wage data are taken from the CMS hospital 
wage survey used to construct the wage index in effect for prospective 
payment purposes during the fiscal year prior to the fiscal year for 
which the hospital requests reclassification.
    (C) If the hospital is requesting reclassification under paragraph 
(e)(1)(iv)(B) of this section, the hospital must provide occupational-
mix data to demonstrate the average occupational mix for each 
employment category in the area to which it seeks reclassification. 
Occupational-mix data can be obtained from surveys conducted by the 
American Hospital Association.
    (ii) For redesignations effective beginning FY 2003:
    (A) For hospital-specific data, the hospital must provide a 
weighted 3-year average of its average hourly wages using data from the 
CMS hospital wage survey used to construct the wage index in effect for 
prospective payment purposes.
    (B) For data for other hospitals, the hospital must provide a 
weighted 3-year average of the average hourly wage in the area in which 
the hospital is located and a weighted 3-year average of the average 
hourly wage in the area to which the hospital seeks reclassification. 
The wage data are taken from the CMS hospital wage survey used to 
construct the wage index in effect for prospective payment purposes.
* * * * *

    11. Section 412.232 is amended by revising paragraph (d)(2) to read 
as follows:


Sec. 412.232  Criteria for all hospitals in a rural county seeking 
urban redesignation.

* * * * *
    (d) Appropriate data. * * *
* * * * *
    (2) Appropriate wage data. The hospitals must submit appropriate 
data as follows:
    (i) For redesignations effective through FY 2002:
    (A) For hospital-specific data, the hospitals must provide data 
from the CMS wage survey used to construct the wage index in effect for 
prospective payment purposes during the fiscal year prior to the fiscal 
year for which the hospitals request reclassification.
    (B) For data for other hospitals, the hospitals must provide the 
following:
    (1) The average hourly wage in the adjacent area, which is taken 
from the CMS hospital wage survey used to

[[Page 39935]]

construct the wage index in effect for prospective payment purposes 
during the fiscal year prior to the fiscal year for which the hospitals 
request reclassification.
    (2) Occupational-mix data to demonstrate the average occupational 
mix for each employment category in the adjacent area. Occupational-mix 
data can be obtained from surveys conducted by the American Hospital 
Association.
    (ii) For redesignations effective beginning FY 2003:
    (A) For hospital-specific data, the hospital must provide a 
weighted 3-year average of its average hourly wages using data from the 
CMS hospital wage survey used to construct the wage index in effect for 
prospective payment purposes.
    (B) For data for other hospitals, the hospital must provide a 
weighted 3-year average of the average hourly wage in the area in which 
the hospital is located and a weighted 3-year average of the average 
hourly wage in the area to which the hospital seeks reclassification. 
The wage data are taken from the CMS hospital wage survey used to 
construct the wage index in effect for prospective payment purposes.

    12. Section 412.235 is added to read as follows:


Sec. 412.235  Criteria for all hospitals in a State seeking a statewide 
wage index redesignation.

    (a) General criteria. For all prospective payment system hospitals 
in a State to be redesignated to a statewide wage index, the following 
conditions must be met:
    (1) All prospective payment system hospitals in the State must 
apply as a group for reclassification to a statewide wage index through 
a signed single application.
    (2) All prospective payment system hospitals in the State must 
agree to the reclassification to a statewide wage index through a 
signed affidavit on the application.
    (3) All prospective payment system hospitals in the State must 
agree, through an affidavit, to withdrawal of an application or to 
termination of an approved statewide wage index reclassification.
    (4) All hospitals in the State must waive their rights to any wage 
index classification that they would otherwise receive absent the 
statewide wage index classification, including a wage index that any of 
the hospitals might have received through individual geographic 
reclassification.
    (5) New hospitals that open within the State prior to the deadline 
for submitting an application for a statewide wage index 
reclassification (September 1), regardless of whether a group 
application has already been filed, must agree to the use of the 
statewide wage index as part of the group application. New hospitals 
that open within the State after the deadline for submitting a 
statewide wage index reclassification application or during the 
approved reclassification period will be considered a party to the 
statewide wage index application and reclassification.
    (b) Effect on payments.
    (1) An individual hospital within the State may receive a wage 
index that could be higher or lower under the statewide wage index 
reclassification in comparison to its otherwise redesignated wage 
index.
    (2) Any new prospective payment system hospital that opens in the 
State during the effective period of an approved statewide wage index 
reclassification will be designated to receive the statewide wage index 
for the duration of that period.
    (c) Terms of the decision.
    (1) A decision by the MGCRB on an application for a statewide wage 
index reclassification will be effective for 3 years beginning with 
discharges occurring on the first day (October 1) of the second Federal 
fiscal year following the Federal fiscal year in which the hospitals 
filed a complete application.
    (2) The procedures and timeframes specified in Sec. 412.273 apply 
to withdrawals of applications for redesignation to a statewide wage 
index and terminations of approved statewide wage index 
reclassifications, including the requirement that, to withdraw an 
application or terminate an approved reclassification, the request must 
be made in writing by all hospitals that are party to the application, 
except hospitals reclassified into the State for purposes of receiving 
the statewide wage index.

    13. Section 412.273 is amended as follows:
    a. The title of the section is revised.
    b. Paragraphs (b) and (c) are redesignated as paragraphs (c) and 
(d), respectively.
    c. A new paragraph (b) is added.
    d. Redesignated paragraph (c) is revised.


Sec. 412.273  Withdrawing an application or terminating an approved 3-
year reclassification.

* * * * *
    (b) Request for termination of approved 3-year wage index 
reclassifications.
    (1) A hospital, or a group of hospitals, that has been issued a 
decision on its application for a 3-year reclassification for wage 
index purposes only or for redesignation to a statewide wage index and 
has not withdrawn that application under the procedures specified in 
paragraph (a) of this section may request termination of its approved 
3-year wage index reclassification under the following conditions:
    (i) The request to terminate must be received by the MGCRB within 
45 days of the publication of the annual notice of proposed rulemaking 
concerning changes to the inpatient hospital prospective payment system 
and proposed payment rates for the fiscal year for which the 
termination is to apply.
    (ii) A request to terminate a 3-year reclassification will be 
effective only for the full fiscal year(s) remaining in the 3-year 
period at the time the request is received. Requests for terminations 
for part of a fiscal year will not be considered.
    (2) Reapplication within the approved 3-year period.
    (i) If a hospital elects to withdraw its wage index application 
after the MGCRB has issued its decision, it may terminate its 
withdrawal in a subsequent fiscal year and request the MGCRB to 
reinstate its wage index reclassification for the remaining fiscal 
year(s) of the 3-year period.
    (ii) A hospital may apply for reclassification for purposes of the 
wage index to a different area (that is, an area different from the one 
to which it was originally reclassified for the 3-year period). If the 
application is approved, the reclassification will be effective for 3 
years.
    (c) Written request only. A request to withdraw an application or 
terminate an approved reclassification must be made in writing to the 
MGCRB by all hospitals that are party to the application or 
reclassification.
* * * * *

    14. Section 412.274 is amended by revising paragraph (b) to read as 
follow:


Sec. 412.274  Scope and effect of an MGCRB decision.

* * * * *
    (b) Effective date and term of the decision.
    (1) A standardized amount classification change is effective for 
one year beginning with discharges occurring on the first day (October 
1) of the second Federal fiscal year following the Federal fiscal year 
in which the complete application is filed and ending effective at the 
end of that Federal fiscal year (the end of the next September 30).
    (2) A wage index classification change is effective for 3 years 
beginning with

[[Page 39936]]

discharges occurring on the first day (October 1) of the second Federal 
fiscal year in which the complete application is filed.
* * * * *

    15. Section 412.348 is amended by revising paragraph (g)(6) and 
adding a new paragraph (g)(9) to read as follows:


Sec. 412.348  Exception payments.

* * * * *
    (g) Special exceptions process. * * *
    (6) Minimum payment level.
    (i) The minimum payment level for qualifying hospitals will be 70 
percent.
    (ii) CMS will adjust the minimum payment level in one percentage 
point increments as necessary to satisfy the requirement specified in 
paragraph (h) of this section that total estimated payments under the 
exceptions process not exceed 10 percent of the total estimated capital 
prospective payment system payments for the same fiscal year.
* * * * *
    (9) Notification requirement. Eligible hospitals must submit 
documentation to the intermediary indicating the completion date of a 
project that meets the project need requirement under paragraph (g)(2) 
of this section, the project size requirement under paragraph (g)(5) of 
this section, and, in the case of certain urban hospitals, an excess 
capacity test under paragraph (g)(4) of this section, by the later of 
October 1, 2001 or within 3 months of the end of the hospital's last 
cost reporting period beginning before October 1, 2001, during which a 
qualifying project was completed.
* * * * *

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR 
END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT 
RATES FOR SKILLED NURSING FACILITIES

    C. Part 413 is amended as follows:
    1. The authority citation for Part 413 continues to read as 
follows:

    Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and 
(n), 1871, 1881, 1883, and 1886 of the Social Security Act (42 
U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 
1395hh, 1395rr, 1395tt, and 1395ww).


    2. Section 413.70 is amended as follows:
    a. Paragraph (a)(1) is republished.
    b. A new paragraph (a)(1)(iv) is added.
    c. Paragraph (a)(2) is revised.
    d. A new paragraph (a)(3) is added.
    e. Paragraph (b)(1) is revised.
    f. Paragraph (b)(2)(i)(C) is revised.
    g. New paragraphs (b)(4), (b)(5) and (b)(6) are added.


Sec. 413.70  Payment for services of a CAH.

    (a) Payment for inpatient services furnished by a CAH.
    (1) Payment for inpatient services of a CAH is the reasonable costs 
of the CAH in providing CAH services to its inpatients, as determined 
in accordance with section 1861(v)(1)(A) of the Act and the applicable 
principles of cost reimbursement in this part and in Part 415 of this 
chapter, except that the following payment principles are excluded when 
determining payment for CAH inpatient services:
* * * * *
    (iv) The payment window provisions for preadmission services, 
specified in Sec. 412.2(c)(5) of this subchapter and Sec. 413.40(c)(2).
    (2) Except as specified in paragraph (a)(3) of this section, 
payment to a CAH for inpatient services does not include any costs of 
physician services or other professional services to CAH inpatients, 
and is subject to the Part A hospital deductible and coinsurance, as 
determined under subpart G of part 409 of this chapter.
    (3) If a CAH meets the criteria in Sec. 412.113(c) of this 
subchapter for pass-through of costs of anesthesia services furnished 
by qualified nonphysician anesthetists employed by the CAH or obtained 
under arrangements, payment to the CAH for the costs of those services 
is made in accordance with Sec. 412.113(c).
    (b) Payment for outpatient services furnished by CAH.
    (1) General.
    (i) Unless the CAH elects to be paid for services to its 
outpatients under the method specified in paragraph (b)(3) of this 
section, the amount of payment for outpatient services of a CAH is the 
amount determined under paragraph (b)(2) of this section.
    (ii) Except as specified in paragraph (b)(6) of this section, 
payment to a CAH for outpatient services does not include any costs of 
physician services or other professional services to CAH outpatients.
    (2) Reasonable costs for facility services.
    (i) * * *
    (C) Any type of reduction to operating or capital costs under 
Sec. 413.124 or Sec. 413.130(j).
* * * * *
    (4) Costs of emergency room on-call physicians.
    (i) Effective for cost reporting periods beginning on or after 
October 1, 2001, the reasonable costs of outpatient CAH services under 
paragraph (b) of this section may include amounts for reasonable 
compensation and related costs for an emergency room physician who is 
on call but who is not present on the premises of the CAH involved, is 
not otherwise furnishing physicians' services, and is not on call at 
any other provider or facility.
    (ii) For purposes of this paragraph (b)(4)--
    (A) ``Amounts for reasonable compensation and related costs'' means 
all allowable costs of compensating emergency room physicians who are 
on call to the extent the costs are found to be reasonable under the 
rules specified in paragraph (b)(2) of this section and the applicable 
sections of Part 413. Costs of compensating emergency room physicians 
are allowable only if the costs are incurred under written contracts 
that require the physician to come to the CAH when the physician's 
presence is medically required.
    (B) An ``emergency room physician who is on call' means a doctor of 
medicine or osteopathy with training or experience in emergency care 
who is immediately available by telephone or radio contact, and is 
available on site within the timeframes specified in Sec. 485.618(d) of 
this chapter.
    (5) Costs of ambulance services.
    (i) Effective for services furnished on or after December 21, 2000, 
payment for ambulance services furnished by a CAH or an entity that is 
owned and operated by a CAH is the reasonable costs of the CAH or the 
entity in furnishing those services, but only if the CAH or the entity 
is the only provider or supplier of ambulance services located within a 
35-mile drive of the CAH or the entity.
    (ii) For purposes of paragraph (b)(5) of this section, the distance 
between the CAH or the entity and the other provider or supplier of 
ambulance services will be determined as the shortest distance in miles 
measured over improved roads between the CAH or the entity and the site 
at which the vehicles of the closest provider or supplier of ambulance 
services are garaged. An improved road for this purpose is any road 
that is maintained by a local, State, or Federal government entity and 
is available for use by the general public. An improved road will be 
considered to include the paved surface up to the front entrance of the 
hospital and the front entrance of the garage.
    (6) If a CAH meets the criteria in Sec. 412.113(c) of this 
subchapter for pass-through of costs of anesthesia services furnished 
by nonphysician anesthetists employed by the CAH or obtained under

[[Page 39937]]

arrangement, payment to the CAH for the costs of those services is made 
in accordance with Sec. 412.113(c) of this chapter.
* * * * *

    3. Section 413.86 is amended as follows:
    a. Paragraph (e)(4)(ii)(C)(1) is revised.
    b. Paragraph (e)(5)(iv) is removed.
    c. Paragraph (g)(4) is revised.
    d. Paragraph (g)(5) is revised.
    e. In paragraph (g)(6), the reference to ``paragraph (g)(9)'' is 
removed and ``paragraph (g)(12)'' is added in its place.
    f. Paragraph (g)(8) is revised.


Sec. 413.86  Direct graduate medical education payments.

* * * * *
    (e) Determining per residents amounts for the base period. * * *
    (4) * * *
    (ii) * * *
    (C) Determining necessary revisions to the per resident amount. * * 
*
    (1) Floor. (i) For cost reporting periods beginning on or after 
October 1, 2000, and before October 1, 2001, if the hospital's per 
resident amount would otherwise be less than 70 percent of the 
locality-adjusted national average per resident amount for FY 2001 (as 
determined under paragraph (e)(4)(ii)(B) of this section), the per 
resident amount is equal to 70 percent of the locality-adjusted 
national average per resident amount for FY 2001.
    (ii) For cost reporting periods beginning on or after October 1, 
2001, and before October 1, 2002, if the hospital's per resident amount 
would otherwise be less than 85 percent of the locality-adjusted 
national average per resident amount for FY 2002 (as determined under 
paragraph (e)(4)(ii)(B) of this section), the per resident amount is 
equal to 85 percent of the locality-adjusted national average per 
resident amount for FY 2002.
    (iii) For subsequent cost reporting periods beginning on or after 
October 1, 2002, the hospital's per resident amount is updated using 
the methodology specified under paragraph (e)(3)(i) of this section.
* * * * *
    (g) Determining the weighted number of FTE residents. * * *
    (4) For purposes of determining direct graduate medical education 
payments--
    (i) For cost reporting periods beginning on or after October 1, 
1997, a hospital's unweighted FTE count for residents in allopathic and 
osteopathic medicine may not exceed the hospital's unweighted FTE count 
(or, effective for cost reporting periods beginning on or after April 
1, 2000, 130 percent of the unweighted FTE count for a hospital located 
in a rural area) for these residents for the most recent cost reporting 
period ending on or before December 31, 1996.
    (ii) If a hospital's number of FTE residents in a cost reporting 
period beginning on or after October 1, 1997, and before October 1, 
2001, exceeds the limit described in this paragraph (g), the hospital's 
total weighted FTE count (before application of the limit) will be 
reduced in the same proportion that the number of FTE residents for 
that cost reporting period exceeds the number of FTE residents for the 
most recent cost reporting period ending on or before December 31, 
1996.
    (iii) If the hospital's number of FTE residents in a cost reporting 
period beginning on or after October 1, 2001 exceeds the limit 
described in this paragraph (g), the hospital's weighted FTE count 
(before application of the limit), for primary care and obstetrics and 
gynecology residents and nonprimary care residents, respectively, will 
be reduced in the same proportion that the number of FTE residents for 
that cost reporting period exceeds the number of FTE residents for the 
most recent cost reporting period ending on or before December 31, 
1996.
    (iv) Hospitals that are part of the same affiliated group may elect 
to apply the limit on an aggregate basis.
    (v) The fiscal intermediary may make appropriate modifications to 
apply the provisions of this paragraph (g)(4) based on the equivalent 
of a 12-month cost reporting period.
    (5) For purposes of determining direct graduate medical education 
payment--
    (i) For the hospital's first cost reporting period beginning on or 
after October 1, 1997, the hospital's weighted FTE count is equal to 
the average of the weighted FTE count for the payment year cost 
reporting period and the preceding cost reporting period.
    (ii) For cost reporting periods beginning on or after October 1, 
1998, and before October 1, 2001, the hospital's weighted FTE count is 
equal to the average of the weighted FTE count for the payment year 
cost reporting period and the preceding two cost reporting periods.
    (iii) For cost reporting periods beginning on or after October 1, 
2001, the hospital's weighted FTE count for primary care and obstetrics 
and gynecology residents is equal to the average of the weighted 
primary care and obstetrics and gynecology counts for the payment year 
cost reporting period and the preceding two cost reporting periods, and 
the hospital's weighted FTE count for nonprimary care residents is 
equal to the average of the weighted nonprimary care FTE counts for the 
payment year cost reporting period and the preceding two cost reporting 
periods.
    (iv) The fiscal intermediary may make appropriate modifications to 
apply the provisions of this paragraph (g)(5) based on the equivalent 
of 12-month cost reporting periods.
    (v) If a hospital qualifies for an adjustment to the limit 
established under paragraph (g)(4) of this section for new medical 
residency programs created under paragraph (g)(6) of this section, the 
count of the residents participating in new medical residency training 
programs above the number included in the hospital's FTE count for the 
cost reporting period ending during calendar year 1996 is added after 
applying the averaging rules in this paragraph (g)(5) for a period of 
years. Residents participating in new medical residency training 
programs are included in the hospital's FTE count before applying the 
averaging rules after the period of years has expired. For purposes of 
this paragraph (g)(5), for each new program started, the period of 
years equals the minimum accredited length for each new program. The 
period of years begins when the first resident begins training in each 
new program.
    (vi) Subject to the regulations at paragraph (g)(8) of this 
section, FTE residents that are displaced by the closure of either 
another hospital or another hospital's program are added to the FTE 
count after applying the averaging rules in this paragraph (g)(5) for 
the receiving hospital for the duration of the time that the displaced 
residents are training at the receiving hospital.
* * * * *
    (8) Closure of hospital or hospital residency program.
    (i) Definitions. For purposes of this paragraph (g)(8)--
    (A) ``Closure of a hospital'' means the hospital terminates its 
Medicare agreement under the provisions of Sec. 489.52 of this chapter.
    (B) ``Closure of a hospital residency training program'' means the 
hospital ceases to offer training for residents in a particular 
approved medical residency training program.
    (ii) Closure of a hospital. A hospital may receive a temporary 
adjustment to its FTE cap to reflect residents added because of another 
hospital's closure if the hospital meets the following criteria:
    (A) The hospital is training additional residents from a hospital 
that closed on or after July 1, 1996.

[[Page 39938]]

    (B) No later than 60 days after the hospital begins to train the 
residents, the hospital submits a request to its fiscal intermediary 
for a temporary adjustment to its FTE cap, documents that the hospital 
is eligible for this temporary adjustment by identifying the residents 
who have come from the closed hospital and have caused the hospital to 
exceed its cap, and specifies the length of time the adjustment is 
needed.
    (iii) Closure of a hospital's residency training program. If a 
hospital that closes its residency training program voluntarily agrees 
to temporarily reduce its FTE cap according to the criteria specified 
in paragraph (g)(8)(iii)(B) of this section, another hospital(s) may 
receive a temporary adjustment to its FTE cap to reflect residents 
added because of the closure of the residency training program if the 
criteria specified in paragraph (g)(8)(iii)(A) of this section are met.
    (A) Receiving hospital(s). A hospital may receive a temporary 
adjustment to its FTE cap to reflect residents added because of the 
closure of another hospital's residency training program if--
    (1) The hospital is training additional residents from the 
residency training program of a hospital that closed a program; and
    (2) No later than 60 days after the hospital begins to train the 
residents, the hospital submits to its fiscal intermediary a request 
for a temporary adjustment to its FTE cap, documents that it is 
eligible for this temporary adjustment by identifying the residents who 
have come from another hospital's closed program and have caused the 
hospital to exceed its cap, specifies the length of time the adjustment 
is needed, and submits to its fiscal intermediary a copy of the FTE 
reduction statement by the hospital that closed its program, as 
specified in paragraph (g)(8)(iii)(B)(2) of this section.
    (B) Hospital that closed its program(s). A hospital that agrees to 
train residents who have been displaced by the closure of another 
hospital's program may receive a temporary FTE cap adjustment only if 
the hospital with the closed program--
    (1) Temporarily reduces its FTE cap based on the FTE residents in 
each program year training in the program at the time of the program's 
closure. This yearly reduction in the FTE cap will be determined based 
on the number of those residents who would have been training in the 
program during that year had the program not closed; and
    (2) No later than 60 days after the residents who were in the 
closed program begin training at another hospital, submit to its fiscal 
intermediary a statement signed and dated by its representative that 
specifies that it agrees to the temporary reduction in its FTE cap to 
allow the hospital training the displaced residents to obtain a 
temporary adjustment to its cap; identifies the residents who were in 
training at the time of the program's closure; identifies the hospitals 
to which the residents are transferring once the program closes; and 
specifies the reduction for the applicable program years.
* * * * *

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

    D. Part 485 is amended as follows:
    1. The authority citation for part 485 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and 
1395hh).

    2. Section 485.610 is amended by revising paragraphs (a)(2)(ii) and 
(b) and adding a new paragraph (c) to read as follows:


Sec. 485.610  Condition of participation: Status and location.

    (a) * * *
    (2) * * *
    (ii) Meets the criteria for designation under this subpart as of 
the effective date of its designation; or
* * * * *
    (b) Standard: Location in a rural area or treatment as rural. The 
CAH meets the requirements of either paragraph (b)(1) or (b)(2) of this 
section.
    (1) The CAH meets the following requirements:
    (i) The CAH is located outside any area that is a Metropolitan 
Statistical Area, as defined by the Office of Management and Budget, or 
that has been recognized as urban under Sec. 412.62(f) of this chapter;
    (ii) The CAH is not deemed to be located in an urban area under 
Sec. 412.63(b) of this chapter; and
    (iii) The CAH has not been classified as an urban hospital for 
purposes of the standardized payment amount by CMS or the Medicare 
Geographic Classification Review Board under Sec. 412.230(e) of this 
chapter, and is not among a group of hospitals that have been 
redesignated to an adjacent urban area under Sec. 412.232 of this 
chapter.
    (2) The CAH is located within a Metropolitan Statistical Area, as 
defined by the Office of Management and Budget, but is being treated as 
being located in a rural area in accordance with Sec. 412.103 of this 
chapter.
    (c) Standard: Location relative to other facilities or necessary 
provider certification. The CAH is located more than a 35-mile drive 
(or, in the case of mountainous terrain or in areas with only secondary 
roads available, a 15-mile drive) from a hospital or another CAH, or 
the CAH is certified by the State as being a necessary provider of 
health care services to residents in the area.

    3. Section 485.639 is amended by revising paragraph (b) to read as 
follows:


Sec. 485.639  Condition of participation: Surgical services.

* * * * *
    (b) Anesthetic risk and evaluation.
    (1) A qualified practitioner, as specified in paragraph (a) of this 
section, must examine the patient immediately before surgery to 
evaluate the risk of the procedure to be performed.
    (2) A qualified practitioner, as specified in paragraph (c) of this 
section, must examine each patient before surgery to evaluate the risk 
of anesthesia.
    (3) Before discharge from the CAH, each patient must be evaluated 
for proper anesthesia recovery by a qualified practitioner, as 
specified in paragraph (c) of this section.
* * * * *

    4. Section 485.643 is amended by revising paragraph (f) to read as 
follows:


Sec. 485.643  Condition of participation: Organ, tissue, and eye 
procurement.

* * * * *
    (f) For purposes of these standards, the term ``organ'' means a 
human kidney, liver, heart, lung, pancreas, or intestines (or 
multivisceral organs).

PART 486--CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED 
BY SUPPLIERS

    F. Part 486 is amended as follows:
    1. The authority citation for Part 486 continues to read as 
follows:

    Authority: Sections 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


    2. Section 486.302 is amended by revising the definition of 
``organ'' to read as follows:


Sec. 486.302  Definitions.

* * * * *
    ``Organ'' means a human kidney, liver, heart, lung, pancreas, or 
intestines (or multivisceral organs).
* * * * *


[[Page 39939]]


(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance)
    Dated: July 23, 2001.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.

    Dated: July 24, 2001.
Tommy G. Thompson,
Secretary.

    Editorial Note: The following Addendum and appendixes will not 
appear in the Code of Federal Regulations.

Addendum--Schedule of Standardized Amounts Effective With 
Discharges Occurring On or After October 1, 2001 and Update Factors 
and Rate-of-Increase Percentages Effective With Cost Reporting 
Periods Beginning On or After October 1, 2001

I. Summary and Background

    In this Addendum, we are setting forth the amounts and factors for 
determining prospective payment rates for Medicare inpatient operating 
costs and Medicare inpatient capital-related costs. We are also setting 
forth rate-of-increase percentages for updating the target amounts for 
hospitals and hospital units excluded from the prospective payment 
system.
    For discharges occurring on or after October 1, 2001, except for 
SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's 
payment per discharge under the prospective payment system will be 
based on 100 percent of the Federal national rate.
    SCHs are paid based on whichever of the following rates yields the 
greatest aggregate payment: the Federal national rate, the updated 
hospital-specific rate based on FY 1982 cost per discharge, the updated 
hospital-specific rate based on FY 1987 cost per discharge, or, if 
qualified, 50 percent of the updated hospital-specific rate based on FY 
1996 cost per discharge, plus the greater of 50 percent of the updated 
FY 1982 or FY 1987 hospital-specific rate or 50 percent of the Federal 
DRG payment rate. Section 213 of Public Law 106-554 amended section 
1886(b)(3) of the Act to allow all SCHs to rebase their hospital-
specific rate based on their FY 1996 cost per discharge.
    Under section 1886(d)(5)(G) of the Act, MDHs are paid based on the 
Federal national rate or, if higher, the Federal national rate plus 50 
percent of the difference between the Federal national rate and the 
updated hospital-specific rate based on FY 1982 or FY 1987 cost per 
discharge, whichever is higher.
    For hospitals in Puerto Rico, the payment per discharge is based on 
the sum of 50 percent of a Puerto Rico rate and 50 percent of a Federal 
national rate. (See section II.D.3. of this Addendum for a complete 
description.)
    As discussed below in section II. of this Addendum, we are making 
changes in the determination of the prospective payment rates for 
Medicare inpatient operating costs for FY 2002. The changes, to be 
applied prospectively, affect the calculation of the Federal rates. In 
section III. of this Addendum, we finalize changes to the prospective 
payment rates for inpatient operating costs for FY 2001, as set forth 
in the June 13, 2001 interim final rule with comment period. In section 
IV. of this Addendum, we discuss our changes for determining the 
prospective payment rates for Medicare inpatient capital-related costs 
for FY 2002. Section V. of this Addendum sets forth our changes for 
determining the rate-of-increase limits for hospitals excluded from the 
prospective payment system for FY 2002. The tables to which we refer in 
the preamble to this final rule are presented at the end of this 
Addendum in section VI.

II. Changes to Prospective Payment Rates for Inpatient Operating 
Costs for FY 2002

    The basic methodology for determining prospective payment rates for 
inpatient operating costs is set forth at Sec. 412.63. The basic 
methodology for determining the prospective payment rates for inpatient 
operating costs for hospitals located in Puerto Rico is set forth at 
Secs. 412.210 and 412.212. Below, we discuss the factors used for 
determining the prospective payment rates. The Federal and Puerto Rico 
rate changes will be effective with discharges occurring on or after 
October 1, 2001.
    In summary, the standardized amounts set forth in Tables 1A and 1C 
of section VI. of this Addendum reflect--
     Updates of 2.75 percent for all areas (that is, the market 
basket percentage increase of 3.3 percent minus 0.55 percentage 
points);
     An adjustment to ensure budget neutrality as provided for 
under sections 1886(d)(4)(C)(iii) and (d)(3)(E) of the Act, by applying 
new budget neutrality adjustment factors to the large urban and other 
standardized amounts;
     An adjustment to ensure budget neutrality as provided for 
in section 1886(d)(8)(D) of the Act by removing the FY 2001 budget 
neutrality factor and applying a revised factor;
     An adjustment to apply the revised outlier offset by 
removing the FY 2001 outlier offsets and applying a new offset; and
     An adjustment in the Puerto Rico standardized amounts to 
reflect the application of a Puerto Rico-specific wage index.

A. Calculation of Adjusted Standardized Amounts

1. Standardization of Base-Year Costs or Target Amounts
    Section 1886(d)(2)(A) of the Act required the establishment of 
base-year cost data containing allowable operating costs per discharge 
of inpatient hospital services for each hospital. The preamble to the 
September 1, 1983 interim final rule (48 FR 39763) contains a detailed 
explanation of how base-year cost data were established in the initial 
development of standardized amounts for the prospective payment system 
and how they are used in computing the Federal rates.
    Section 1886(d)(9)(B)(i) of the Act required us to determine the 
Medicare target amounts for each hospital located in Puerto Rico for 
its cost reporting period beginning in FY 1987. The September 1, 1987 
final rule (52 FR 33043, 33066) contains a detailed explanation of how 
the target amounts were determined and how they are used in computing 
the Puerto Rico rates.
    The standardized amounts are based on per discharge averages of 
adjusted hospital costs from a base period or, for Puerto Rico, 
adjusted target amounts from a base period, updated and otherwise 
adjusted in accordance with the provisions of section 1886(d) of the 
Act. Sections 1886(d)(2)(B) and (d)(2)(C) of the Act required us to 
update base-year per discharge costs for FY 1984 and then standardize 
the cost data in order to remove the effects of certain sources of cost 
variations among hospitals. These effects include case-mix, differences 
in area wage levels, cost-of-living adjustments for Alaska and Hawaii, 
indirect medical education (IME) costs, and costs to hospitals serving 
a disproportionate share of low-income patients.
    Under sections 1886(d)(2)(H) and (d)(3)(E) of the Act, in making 
payments under the prospective payment system, the Secretary estimates 
from time to time the proportion of costs that are wages and wage-
related costs. Since October 1, 1997, when the market basket was last 
revised, we have considered 71.1 percent of costs to be labor-related 
for purposes of the prospective payment system. The average labor share 
in Puerto Rico is 71.3 percent. We are revising the discharge-weighted 
national standardized amount for Puerto Rico to

[[Page 39940]]

reflect the proportion of discharges in large urban and other areas 
from the FY 2000 MedPAR file.
2. Computing Large Urban and Other Area Averages
    Sections 1886(d)(2)(D) and (d)(3) of the Act require the Secretary 
to compute two average standardized amounts for discharges occurring in 
a fiscal year: one for hospitals located in large urban areas and one 
for hospitals located in other areas. In addition, under sections 
1886(d)(9)(B)(iii) and (d)(9)(C)(i) of the Act, the average 
standardized amount per discharge must be determined for hospitals 
located in large urban and other areas in Puerto Rico. Hospitals in 
Puerto Rico are paid a blend of 50 percent of the applicable Puerto 
Rico standardized amount and 50 percent of a national standardized 
payment amount.
    Section 1886(d)(2)(D) of the Act defines ``urban area'' as those 
areas within a Metropolitan Statistical Area (MSA). A ``large urban 
area'' is defined as an urban area with a population of more than 1 
million. In addition, section 4009(i) of Public Law 100-203 provides 
that a New England County Metropolitan Area (NECMA) with a population 
of more than 970,000 is classified as a large urban area. As required 
by section 1886(d)(2)(D) of the Act, population size is determined by 
the Secretary based on the latest population data published by the 
Bureau of the Census. Urban areas that do not meet the definition of a 
``large urban area'' are referred to as ``other urban areas.'' Areas 
that are not included in MSAs are considered ``rural areas'' under 
section 1886(d)(2)(D) of the Act. Payment for discharges from hospitals 
located in large urban areas will be based on the large urban 
standardized amount. Payment for discharges from hospitals located in 
other urban and rural areas will be based on the other standardized 
amount.
    Based on 1999 population estimates published by the Bureau of the 
Census, 63 areas meet the criteria to be defined as large urban areas 
for FY 2002. These areas are identified in Table 4A.
3. Updating the Average Standardized Amounts
    Under section 1886(d)(3)(A) of the Act, we update the average 
standardized amounts each year. In accordance with section 
1886(d)(3)(A)(iv) of the Act, we are updating the large urban areas' 
and the other areas' average standardized amounts for FY 2002 using the 
applicable percentage increases specified in section 1886(b)(3)(B)(i) 
of the Act. Section 1886(b)(3)(B)(i)(XVII) of the Act as amended by 
section 301 of Public Law 106-554 specifies that the update factor for 
the standardized amounts for FY 2002 is equal to the market basket 
percentage increase minus 0.55 percentage points for hospitals in all 
areas. Section 301 also established that the update factor for FY 2003 
is equal to the market basket percentage increase minus 0.55 percentage 
points. We are revising Sec. 412.63 to reflect these changes.
    The percentage change in the market basket reflects the average 
change in the price of goods and services purchased by hospitals to 
furnish inpatient care. The most recent forecast of the hospital market 
basket increase for FY 2002 is 3.3 percent. Thus, for FY 2002, the 
update to the average standardized amounts equals 2.75 percent for 
hospitals in all areas.
    As in the past, we are adjusting the FY 2001 standardized amounts 
to remove the effects of the FY 2001 geographic reclassifications and 
outlier payments before applying the FY 2002 updates. That is, we are 
increasing the standardized amounts to restore the reductions that were 
made for the effects of geographic reclassification and outliers. We 
then apply the new offsets to the standardized amounts for outliers and 
geographic reclassifications for FY 2002.
    Although the update factors for FY 2002 are set by law, we are 
required by section 1886(e)(3) of the Act to report to the Congress our 
initial recommendation of update factors for FY 2002 for both 
prospective payment hospitals and hospitals excluded from the 
prospective payment system.
    We have included our final recommendations on the update factors in 
Appendix C to this final rule.
    4. Other Adjustments to the Average Standardized Amounts
a. Recalibration of DRG Weights and Updated Wage Index--Budget 
Neutrality Adjustment
    Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning in 
FY 1991, the annual DRG reclassification and recalibration of the 
relative weights must be made in a manner that ensures that aggregate 
payments to hospitals are not affected. As discussed in section II of 
the preamble, we normalized the recalibrated DRG weights by an 
adjustment factor, so that the average case weight after recalibration 
is equal to the average case weight prior to recalibration.
    Section 1886(d)(3)(E) of the Act requires us to update the hospital 
wage index on an annual basis beginning October 1, 1993. This provision 
also requires us to make any updates or adjustments to the wage index 
in a manner that ensures that aggregate payments to hospitals are not 
affected by the change in the wage index.
    To comply with the requirement of section 1886(d)(4)(C)(iii) of the 
Act that DRG reclassification and recalibration of the relative weights 
be budget neutral, and the requirement in section 1886(d)(3)(E) of the 
Act that the updated wage index be budget neutral, we used FY 2000 
discharge data to simulate payments and compared aggregate payments 
using the FY 2001 relative weights and wage index to aggregate payments 
using the FY 2002 relative weights and wage index. The same methodology 
was used for the FY 2001 budget neutrality adjustment. (See the 
discussion in the September 1, 1992 final rule (57 FR 39832).) Based on 
this comparison, we computed a budget neutrality adjustment factor 
equal to 0.995821. We also adjust the Puerto Rico-specific standardized 
amounts for the effect of DRG reclassification and recalibration. We 
computed a budget neutrality adjustment factor for Puerto Rico-specific 
standardized amounts equal to 0.997209. These budget neutrality 
adjustment factors are applied to the standardized amounts without 
removing the effects of the FY 2001 budget neutrality adjustments. For 
FY 2001, we used an average of the budget neutrality factor that was in 
effect from October 1, 2000 through March 30, 2001 and the budget 
neutrality factor that was in effect from April 1, 2001 through 
September 30, 2001 (0.997225 and 0.997122, respectively). We do not 
remove the prior budget neutrality adjustment because estimated 
aggregate payments after the changes in the DRG relative weights and 
wage index should equal estimated aggregate payments prior to the 
changes. If we removed the prior year adjustment, we would not satisfy 
this condition.
    In addition, we will continue to apply these same adjustment 
factors to the hospital-specific rates that are effective for cost 
reporting periods beginning on or after October 1, 2001. (See the 
discussion in the September 4, 1990 final rule (55 FR 36073).)
b. Reclassified Hospitals--Budget Neutrality Adjustment
    Section 1886(d)(8)(B) of the Act provides that, effective with 
discharges occurring on or after October 1, 1988, certain rural 
hospitals are deemed urban. In addition, section 1886(d)(10) of the Act 
provides for the reclassification of hospitals based on determinations 
by the Medicare

[[Page 39941]]

Geographic Classification Review Board (MGCRB). Under section 
1886(d)(10) of the Act, a hospital may be reclassified for purposes of 
the standardized amount or the wage index, or both.
    Under section 1886(d)(8)(D) of the Act, the Secretary is required 
to adjust the standardized amounts so as to ensure that aggregate 
payments under the prospective payment system after implementation of 
the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the 
Act are equal to the aggregate prospective payments that would have 
been made absent these provisions. To calculate this budget neutrality 
factor, we used FY 2000 discharge data to simulate payments, and 
compared total prospective payments (including IME and disproportionate 
share hospital (DSH) payments) prior to any reclassifications to total 
prospective payments after reclassifications. Based on these 
simulations, we are applying an adjustment factor of 0.990675 to ensure 
that the effects of reclassification are budget neutral.
    The adjustment factor is applied to the standardized amounts after 
removing the effects of the FY 2001 budget neutrality adjustment 
factor. We note that the proposed FY 2002 adjustment reflected wage 
index and standardized amount reclassifications approved by the MGCRB 
or the Administrator as of February 28, 2001, and the effects of 
section 304 of Public Law 106-554 to extend wage index 
reclassifications for 3 years. The effects of any additional 
reclassification changes that occurred as a result of appeals and 
reviews of the MGCRB decisions for FY 2002 or from a hospital's request 
for the withdrawal of a reclassification request for FY 2002 are 
reflected in the final budget neutrality adjustment required under 
section 1886(d)(8)(D) of the Act and published in this final rule.
c. Outliers
    Section 1886(d)(5)(A) of the Act provides for payments in addition 
to the basic prospective payments for ``outlier'' cases, cases 
involving extraordinarily high costs (cost outliers). Section 
1886(d)(3)(B) of the Act requires the Secretary to adjust both the 
large urban and other area national standardized amounts by the same 
factor to account for the estimated proportion of total DRG payments 
made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act 
requires the Secretary to adjust the large urban and other standardized 
amounts applicable to hospitals in Puerto Rico to account for the 
estimated proportion of total DRG payments made to outlier cases. 
Furthermore, under section 1886(d)(5)(A)(iv) of the Act, outlier 
payments for any year must be projected to be not less than 5 percent 
nor more than 6 percent of total payments based on DRG prospective 
payment rates.
    i. FY 2002 outlier thresholds. For FY 2001, the fixed loss cost 
outlier threshold published in the August 1, 2000 final rule was equal 
to the prospective payment rate for the DRG plus the IME and DSH 
payments plus $17,550 ($16,036 for hospitals that have not yet entered 
the prospective payment system for capital-related costs). As a result 
of the change made by Public Law 106-554 to the update factor for the 
operating standardized amounts, this threshold was applicable for 
discharges on or after October 1, 2000 and before April 1, 2001. For 
discharges occurring on or after April 1, 2001 and before October 1, 
2001, the threshold was equal to the prospective payment rate for the 
DRG plus the IME and DSH payments plus $16,350 ($14,940 for hospitals 
that have not yet entered the prospective payment system for capital-
related costs). The revision to the threshold was discussed in the 
interim final rule with comment period published on June 13, 2001 (66 
FR 32176). (In the June 13, 2001 interim final rule with comment 
period, the fixed loss amount was stated as $16,500. This was an error; 
the correct amount is $16,350. This is the amount that has been applied 
to discharges since April 1, 2001, in the PRICER software used to 
determine payments.) The marginal cost factor for cost outliers (the 
percent of costs paid after costs for the case exceed the threshold) 
was 80 percent.
    For FY 2002, we proposed to establish a fixed loss cost outlier 
threshold equal to the prospective payment rate for the DRG plus the 
IME and DSH payments plus $21,000. The capital prospective payment 
system is fully phased in, effective FY 2002. Therefore, we no longer 
are establishing a separate threshold for hospitals that have not yet 
entered the prospective payment system for capital-related costs. We 
proposed to maintain the marginal cost factor for cost outliers at 80 
percent.
    In this final rule, we are establishing a fixed loss cost outlier 
threshold equal to the prospective rate for the DRG plus the IME and 
DSH payment plus $21,025. In addition, we are maintaining the marginal 
cost factor for cost outliers at 80 percent. To calculate the final FY 
2002 outlier thresholds, we simulated payments by applying FY 2002 
rates and policies to the March 2001 update of the FY 2000 MedPAR file 
and the March 2001 update of the Provider-Specific File.
    We apply a cost inflation factor to update costs for the cases used 
to simulate payments. For FY 2000, we used a cost inflation factor of 
zero percent. For FY 2001, we used a cost inflation factor (or cost 
adjustment factor) of 1.8 percent. To set the proposed FY 2002 outlier 
thresholds, we used a 2-year cost inflation factor of 5.5 percent (to 
inflate FY 2000 charges to FY 2002). We are using a cost inflation 
factor of 2.8 percent per year to set the final FY 2002 outlier 
thresholds (this equates to a 2-year cost inflation factor of 5.7 
percent). This factor reflects our analysis of the best available cost 
report data as well as calculations (using the best available data) 
indicating that the percentage of actual outlier payments for FY 2000 
is higher than we projected before the beginning of FY 2000, and that 
the percentage of actual outlier payments for FY 2001 will likely be 
higher than we projected before the beginning of FY 2001. The 
calculations of ``actual'' outlier payments are discussed further 
below.
    Comment: Several commenters noted that the proposed threshold was 
almost 20 percent higher than the threshold effective for FY 2001. The 
commenters believed that we should verify the amount of cost outliers 
paid in a year and reconcile accordingly. One commenter also suggested 
that we amend our method of calculating the threshold so that the 
threshold is set at a level that reflects FY 2001 threshold plus a 
reasonable updating factor to account for inflation.
    Response: As indicated in the proposed rule, and as explained in 
numerous previous Federal Register documents, under the policy we have 
maintained since the inception of the hospital inpatient prospective 
payment system for operating costs, we do not make retroactive 
adjustments to reconcile differences between the percentage of outlier 
payments projected before a given fiscal year and the ``actual'' 
outlier payments for that fiscal year.
    In accordance with section 1886(d)(5)(A) of the Act, we set outlier 
thresholds for an upcoming fiscal year so that outlier payments for the 
fiscal year are projected to equal a specified percentage between 5 and 
6 percent of total payments based on DRG prospective payment rates. To 
set the thresholds, we simulate payments using the best available data. 
We believe that the methodology suggested by the commenter, simply 
updating the FY 2001 thresholds to account for inflation,

[[Page 39942]]

would not be appropriate because, among other reasons, the methodology 
would not reflect the use of the most recent complete data with respect 
to discharges and costs. The difference between the FY 2001 outlier 
thresholds and the FY 2002 outlier thresholds arises from differences 
reflected in the data used to set the respective thresholds.
    ii. Other changes concerning outliers. In accordance with section 
1886(d)(5)(A)(iv) of the Act, we calculated outlier thresholds so that 
outlier payments are projected to equal 5.1 percent of total payments 
based on DRG prospective payment rates. In accordance with section 
1886(d)(3)(E), we reduced the FY 2002 standardized amounts by the same 
percentage to account for the projected proportion of payments paid to 
outliers.
    As stated in the September 1, 1993 final rule (58 FR 46348), we 
establish outlier thresholds that are applicable to both inpatient 
operating costs and inpatient capital-related costs. When we modeled 
the combined operating and capital outlier payments, we found that 
using a common set of thresholds resulted in a higher percentage of 
outlier payments for capital-related costs than for operating costs. We 
project that the thresholds for FY 2002 will result in outlier payments 
equal to 5.1 percent of operating DRG payments and 5.8 percent of 
capital payments based on the Federal rate.
    The proposed outlier adjustment factors applied to the standardized 
amounts for FY 2002 were as follows:

------------------------------------------------------------------------
                                                 Operating     Capital
                                               standardized    federal
                                                  amounts        rate
------------------------------------------------------------------------
National.....................................      0.948910     0.974711
Puerto Rico..................................      0.942593     0.970336
------------------------------------------------------------------------

    Based on simulations of payments using updated data, the final 
outlier adjustment factors applied to the standardized amounts for FY 
2002 are as follows:

------------------------------------------------------------------------
                                                 Operating     Capital
                                               standardized    federal
                                                  amounts        rate
------------------------------------------------------------------------
National.....................................      0.948928     0.942440
Puerto Rico..................................      0.974762     0.970140
------------------------------------------------------------------------

    As in the proposed rule, we apply the outlier adjustment factors 
after removing the effects of the FY 2001 outlier adjustment factors on 
the standardized amounts.
    Table 8A in section VI. of this Addendum contains the updated 
statewide average operating cost-to-charge ratios for urban hospitals 
and for rural hospitals to be used in calculating cost outlier payments 
for those hospitals for which the fiscal intermediary is unable to 
compute a reasonable hospital-specific cost-to-charge ratio. These 
statewide average ratios replace the ratios published in the August 1, 
2000 final rule (65 FR 47054). Table 8B contains comparable statewide 
average capital cost-to-charge ratios. These average ratios will be 
used to calculate cost outlier payments for those hospitals for which 
the fiscal intermediary computes operating cost-to-charge ratios lower 
than 0.1903547 or greater than 1.3148656 and capital cost-to-charge 
ratios lower than 0.0119230 or greater than 0.1677417. This range 
represents 3.0 standard deviations (plus or minus) from the mean of the 
log distribution of cost-to-charge ratios for all hospitals. We note 
that the cost-to-charge ratios in Tables 8A and 8B will be used during 
FY 2002 when hospital-specific cost-to-charge ratios based on the 
latest settled cost report are either not available or outside the 
three standard deviations range.
    iii. FY 2000 and FY 2001 outlier payments. In the August 1, 2000 
final rule (65 FR 47054), we stated that, based on available data, we 
estimated that actual FY 2000 outlier payments would be approximately 
6.2 percent of actual total DRG payments. This was computed by 
simulating payments using the March 2000 update of the FY 1999 bill 
data available at the time. That is, the estimate of actual outlier 
payments did not reflect actual FY 2000 bills but instead reflected the 
application of FY 2000 rates and policies to available FY 1999 bills. 
Our current estimate, using available FY 2000 bills, is that actual 
outlier payments for FY 2000 were approximately 7.6 percent of actual 
total DRG payments. We note that the MedPAR file for FY 2000 discharges 
continues to be updated. Thus, the data indicate that, for FY 2000, the 
percentage of actual outlier payments relative to actual total payments 
is higher than we projected before FY 2000 (and thus exceeds the 
percentage by which we reduced the standardized amounts for FY 2000). 
In fact, the data indicate that the proportion of actual outlier 
payments for FY 2000 exceeds 6.0 percent. Nevertheless, consistent with 
the policy and statutory interpretation we have maintained since the 
inception of the prospective payment system, we do not plan to recoup 
money and make retroactive adjustments to outlier payments for FY 2000.
    We currently estimate that actual outlier payments for FY 2001 will 
be approximately 6.2 percent of actual total DRG payments, 1.1 
percentage points higher than the 5.1 percent we projected in setting 
outlier policies for FY 2001. This estimate is based on simulations 
using the March 2001 update of the Provider-Specific File and the March 
2001 update of the FY 2000 MedPAR file (discharge data for FY 2000 
bills). We used these data to calculate an estimate of the actual 
outlier percentage for FY 2001 by applying FY 2001 rates and policies 
to available FY 2000 bills.
5. FY 2002 Standardized Amounts
    The adjusted standardized amounts are divided into labor and 
nonlabor portions. Table 1A contains the two national standardized 
amounts that are applicable to all hospitals, except hospitals in 
Puerto Rico. Under section 1886(d)(9)(A)(ii) of the Act, the Federal 
portion of the Puerto Rico payment rate is based on the discharge-
weighted average of the national large urban standardized amount and 
the national other standardized amount (as set forth in Table 1A). The 
labor and nonlabor portions of the national average standardized 
amounts for Puerto Rico hospitals are set forth in Table 1C. This table 
also includes the Puerto Rico standardized amounts.
    Comment: Several commenters were unable to reconcile the 
standardized amounts published in the proposed rule for FY 2002 with 
the rates which were in effect for FY 2001. These commenters requested 
that we clarify, by category, the increases and decreases applied to 
the standardized amounts in the proposed rule in order to illustrate 
the method under which the rates were established.
    Response: The confusion likely arises from the two different rates 
that were effective during FY 2001. Prior to the passage of Public Law 
106-554, section 1886(b)(3)(B)(i) of the Act set the update to the 
standardized amounts for FY 2001 as the market basket percentage 
increase minus 1.1 percentage points. Section 301(a) of Public Law 106-
554 revised section 1886(b)(3)(B)(i) of the Act to set the update to 
the standardized amounts for FY 2001 equal to the full market basket 
percentage increase.
    Further, section 301(b) of Public Law 106-554 included a special 
provision to implement the full market basket update for purposes of 
making payments for FY 2001 only. Under this special provision, for 
discharges occurring on or after October 1, 2000 and before April 1, 
2001, the update factor (other than for SCHs) is equal to the market 
basket percentage increase minus 1.1

[[Page 39943]]

percentage points. For discharges occurring on or after April 1, 2001 
and before October 1, 2001, the update factor (other than SCHs) is 
equal to the market basket percentage increase plus 1.1 percentage 
points.
    However, section 547 of Public Law 106-554 makes this special rule 
applicable solely to payments in FY 2001 and the payment increases 
under section 301(b) in this fiscal year are not to be taken into 
account in developing payments for future fiscal years. Consequently, 
when we established the rates for FY 2002, we based the calculation on 
FY 2001 standardized amounts reflecting the full FY 2001 market basket 
percentage increase of 3.4 percent. Since the standardized amounts 
calculated using the full market basket were not actually used for 
payment during FY 2001, they were not published in either the August 1, 
2000 final rule or the June 13, 2001 interim final rule with comment 
period.
    To arrive at the final FY 2002 standardized amounts, we updated the 
standardized amounts through FY 2001 using the full market basket of 
3.4 percent (without applying a geographic budget neutrality factor or 
outlier factor), then multiplied this amount by: the update factor for 
FY 2002; the wage and recalibration budget neutrality factor; the 
geographic reclassification budget neutrality factor; and the outlier 
factor established for FY 2002. The calculation below details this 
reconciliation process using the large urban area standardized amount 
as an example. Although the commenters requested a reconciliation of 
the proposed rates, the example below reconciles the final FY 2002 
rates, as those are the amounts actually in effect for the fiscal year. 
To reconcile the rates in the proposed rule, the exact same methodology 
applies.

 Example of the Calculation of the FY 2002 Final Standardized Amount for
                            Large Urban Areas
------------------------------------------------------------------------
                                                   Labor       Nonlabor
------------------------------------------------------------------------
FY 2001 Standardized Amount with Full Market      $3,072.51    $1,248.88
 Basket Update/No Reclassification, Budget
 Neutrality or Outlier Offset.................
Update Factor: (Market Basket Percentage             1.0275       1.0275
 Increase minus 0.55 percent).................
FY 2002 Wage Index and DRG reclassification/       0.995821     0.995821
 recalculation budget neutrality factor.......
FY 2002 Reclassification budget neutrality         0.990675     0.990675
 factor.......................................
Outlier Factor................................     0.948928     0.948928
Final Rate for FY 2002 (after multiplying FY      $2,955.44    $1,201.30
 2001 base rate by above factors).............
------------------------------------------------------------------------

B. Adjustments for Area Wage Levels and Cost of Living

    Tables 1A and 1C, as set forth in this Addendum, contain the labor-
related and nonlabor-related shares that will be used to calculate the 
prospective payment rates for hospitals located in the 50 States, the 
District of Columbia, and Puerto Rico. This section addresses two types 
of adjustments to the standardized amounts that are made in determining 
the prospective payment rates as described in this Addendum.
1. Adjustment for Area Wage Levels
    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require 
that we make an adjustment to the labor-related portion of the 
prospective payment rates to account for area differences in hospital 
wage levels. This adjustment is made by multiplying the labor-related 
portion of the adjusted standardized amounts by the appropriate wage 
index for the area in which the hospital is located. In section III. of 
this preamble, we discuss the data and methodology for the FY 2002 wage 
index. The wage index is set forth in Tables 4A, 4B, 4C, and 4F of this 
Addendum.
2. Adjustment for Cost-of-Living in Alaska and Hawaii
    Section 1886(d)(5)(H) of the Act authorizes an adjustment to take 
into account the unique circumstances of hospitals in Alaska and 
Hawaii. Higher labor-related costs for these two States are taken into 
account in the adjustment for area wages described above. For FY 2002, 
we are adjusting the payments for hospitals in Alaska and Hawaii by 
multiplying the nonlabor portion of the standardized amounts by the 
appropriate adjustment factor contained in the table below.

 Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Alaska--All areas..........................  1.25
Hawaii:
  County of Honolulu.......................  1.25
  County of Hawaii.........................  1.165
  County of Kauai..........................  1.2325
  County of Maui...........................  1.2375
  County of Kalawao........................  1.2375
------------------------------------------------------------------------

    (The above factors are based on data obtained from the U.S. Office 
of Personnel Management.)

C. DRG Relative Weights

    As discussed in section II. of the preamble, we have developed a 
classification system for all hospital discharges, assigning them into 
DRGs, and have developed relative weights for each DRG that reflect the 
resource utilization of cases in each DRG relative to Medicare cases in 
other DRGs. Table 5 of section VI. of this Addendum contains the 
relative weights that we will use for discharges occurring in FY 2002. 
These factors have been recalibrated as explained in section II. of the 
preamble.

D. Calculation of Prospective Payment Rates for FY 2002

General Formula for Calculation of Prospective Payment Rates for FY 
2002
    The prospective payment rate for all hospitals located outside of 
Puerto Rico, except SCHs and MDHs, equals the Federal rate.
    The prospective payment rate for SCHs equals whichever of the 
following rates yields the greatest aggregate payment: the Federal 
rate, the updated hospital-specific rate based on FY 1982 cost per 
discharge, the updated hospital-specific rate based on FY 1987 cost per 
discharge, or, if qualified, 50 percent of the updated hospital-
specific rate based on FY 1996 cost per discharge, plus the greater of 
50 percent of the updated FY 1982 or FY 1987 hospital-specific rate or 
50 percent of the Federal rate. Section 213 of Public Law 106-554 
amended section 1886(b)(3) of the Act to allow all SCHs to rebase their 
hospital-specific rate based on their FY 1996 cost per discharge.
    The prospective payment rate for MDHs equals 100 percent of the 
Federal rate, or, if the greater of the updated FY 1982 hospital-
specific rate or the updated FY 1987 hospital-specific rate is higher 
than the Federal rate, 100 percent of the Federal rate plus 50 percent 
of the difference between the applicable hospital-specific rate and the 
Federal rate.
    The prospective payment rate for Puerto Rico equals 50 percent of 
the

[[Page 39944]]

Puerto Rico rate plus 50 percent of a discharge-weighted average of the 
Federal large urban standardized amount and the Federal other 
standardized amount.
1. Federal Rate
    For discharges occurring on or after October 1, 2001 and before 
October 1, 2002, except for SCHs, MDHs, and hospitals in Puerto Rico, 
the hospital's payment is based exclusively on the Federal national 
rate. The payment amount is determined as follows:
    Step 1--Select the appropriate national standardized amount 
considering the type of hospital and designation of the hospital as 
large urban or other (see Table 1A in section VI. of this Addendum).
    Step 2--Multiply the labor-related portion of the standardized 
amount by the applicable wage index for the geographic area in which 
the hospital is located (see Tables 4A, 4B, and 4C of section VI. of 
this Addendum).
    Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-
related portion of the standardized amount by the appropriate cost-of-
living adjustment factor.
    Step 4--Add the amount from Step 2 and the nonlabor-related portion 
of the standardized amount (adjusted, if appropriate, under Step 3).
    Step 5--Multiply the final amount from Step 4 by the relative 
weight corresponding to the appropriate DRG (see Table 5 of section VI. 
of this Addendum).
2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)
    Section 1886(b)(3)(C) of the Act provides that SCHs are paid based 
on whichever of the following rates yields the greatest aggregate 
payment: the Federal rate, the updated hospital-specific rate based on 
FY 1982 cost per discharge, the updated hospital-specific rate based on 
FY 1987 cost per discharge, or, if qualified, 50 percent of the updated 
hospital-specific rate based on FY 1996 cost per discharge, plus the 
greater of 50 percent of the updated FY 1982 or FY 1987 hospital-
specific rate or 50 percent of the Federal DRG payment rate.
    Section 1886(d)(5)(G) of the Act provides that MDHs are paid based 
on whichever of the following rates yields the greatest aggregate 
payment: the Federal rate or the Federal rate plus 50 percent of the 
difference between the Federal rate and the greater of the updated 
hospital-specific rate based on FY 1982 and FY 1987 cost per discharge.
    Hospital-specific rates have been determined for each of these 
hospitals based on either the FY 1982 cost per discharge, the FY 1987 
cost per discharge or, for qualifying SCHs, the FY 1996 cost per 
discharge. For a more detailed discussion of the calculation of the 
hospital-specific rates, we refer the reader to the September 1, 1983 
interim final rule (48 FR 39772); the April 20, 1990 final rule with 
comment (55 FR 15150); the September 4, 1990 final rule (55 FR 35994); 
and the August 1, 2000 final rule (65 FR 47082).
a. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates 
for FY 2002
    We are increasing the hospital-specific rates by 2.75 percent (the 
hospital market basket percentage increase minus 0.55 percentage 
points) for SCHs and MDHs for FY 2002. Section 1886(b)(3)(C)(iv) of the 
Act provides that the update factor applicable to the hospital-specific 
rates for SCHs equal the update factor provided under section 
1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2002, is the market 
basket rate of increase minus 0.55 percentage points. Section 
1886(b)(3)(D) of the Act provides that the update factor applicable to 
the hospital-specific rates for MDHs equals the update factor provided 
under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2002, is the 
market basket rate of increase minus 0.55 percentage points.
b. Calculation of Hospital-Specific Rate
    For SCHs, the applicable FY 2002 hospital-specific rate is based on 
the following: the hospital-specific rate calculated using the greater 
of the FY 1982 or FY 1987 costs, increased by the applicable update 
factor; or, if the hospital-specific rate based on cost per case in FY 
1996 is greater than the hospital-specific rate using either the FY 
1982 or the FY 1987 costs, the greater of 50 percent of the hospital-
specific rate based on the FY 1982 or FY 1987 costs, increased by the 
applicable update factor, or 50 percent of the Federal rate plus 50 
percent of its rebased FY 1996 hospital-specific rate updated through 
FY 2002. For MDHs, the applicable FY 2002 hospital-specific rate is 
calculated by increasing the hospital's hospital-specific rate for the 
preceding fiscal year by the applicable update factor, which is the 
same as the update for all prospective payment hospitals. In addition, 
for both SCHs and MDHs, the hospital-specific rate is adjusted by the 
budget neutrality adjustment factor (that is, by 0.995821) as discussed 
in section II.A.4.a. of this Addendum. The resulting rate is used in 
determining the payment rate an SCH or MDH is paid for its discharges 
beginning on or after October 1, 2001.
3. General Formula for Calculation of Prospective Payment Rates for 
Hospitals Located in Puerto Rico Beginning On or After October 1, 2001 
and Before October 1, 2002
a. Puerto Rico Rate
    The Puerto Rico prospective payment rate is determined as follows:
    Step 1--Select the appropriate adjusted average standardized amount 
considering the large urban or other designation of the hospital (see 
Table 1C of section VI. of the Addendum).
    Step 2--Multiply the labor-related portion of the standardized 
amount by the appropriate Puerto Rico-specific wage index (see Table 4F 
of section VI. of the Addendum).
    Step 3--Add the amount from Step 2 and the nonlabor-related portion 
of the standardized amount.
    Step 4--Multiply the result in Step 3 by 50 percent.
    Step 5--Multiply the amount from Step 4 by the appropriate DRG 
relative weight (see Table 5 of section VI. of the Addendum).
b. National Rate
    The national prospective payment rate is determined as follows:
    Step 1--Multiply the labor-related portion of the national average 
standardized amount (see Table 1C of section VI. of the Addendum) by 
the appropriate national wage index (see Tables 4A and 4B of section 
VI. of the Addendum).
    Step 2--Add the amount from Step 1 and the nonlabor-related portion 
of the national average standardized amount.
    Step 3--Multiply the result in Step 2 by 50 percent.
    Step 4--Multiply the amount from Step 3 by the appropriate DRG 
relative weight (see Table 5 of section VI. of the Addendum).
    The sum of the Puerto Rico rate and the national rate computed 
above equals the prospective payment for a given discharge for a 
hospital located in Puerto Rico.

III. Changes to the Prospective Payment Rates for Inpatient 
Operating Costs for FY 2001 (Section 301 of Public Law 106-554 and 
42 CFR 412.63(s))

    In the June 13, 2001 interim final rule with comment period, we 
implemented section 301(a) of Public Law 106-554 as it applied to FY 
2001. Section 301(a) amended section 1886(b)(3)(B)(i) of the Act by 
changing the percentage increase for the hospital inpatient payment 
rates

[[Page 39945]]

for FYs 2001, 2002, and 2003. Previously, section 1886(b)(3)(B)(i) (as 
amended by section 406 of Public Law 106-113) established the update 
factor to the payment rates for inpatient prospective payment system 
hospitals (other than SCHs, who received the full market basket update 
effective October 1, 2000) as the market basket percentage increase 
minus 1.1 percent for FYs 2001 and 2002; the update factor for FY 2003 
and subsequent fiscal years was established as the full market basket 
percentage increase. Section 301(a) of Public Law 106-554 amended 
section 1886(b)(3)(B)(i) of the Act and changed the update factor for 
FY 2001 to the full market basket percentage increase. (Section 301(a) 
also revised the update factors that apply to FYs 2002 and 2003, as 
discussed in section II. of this Addendum.) Prior to enactment of 
Public Law 106-554, the update factor for FY 2002 was the market basket 
percentage increase minus 1.1 percentage points and the update factor 
for FY 2003 was the full market basket percentage increase. Section 
301(a) of Public Law 106-554 amended section 1886(b)(3)(B)(i) of the 
Act to revise the update factor for FYs 2002 and 2003 to be the market 
basket percentage increase minus 0.55 percentage points.
    Further, section 301(b) of Public Law 106-554 provided a special 
rule to implement the full market basket update to inpatient hospital 
prospective payment rates for FY 2001. Under this special rule, for 
discharges occurring on or after October 1, 2000 and before April 1, 
2001, the update factor for inpatient prospective payment system 
hospitals (other than SCHs) is equal to the market basket percentage 
increase minus 1.1 percentage points. For discharges occurring on or 
after April 1, 2001 and before October 1, 2001, the update factor for 
the payment rates for inpatient prospective payment system hospitals 
(other than SCHs) is equal to the market basket percentage increase 
plus 1.1 percentage points. Section 547 of Public Law 106-554 makes 
this special rule applicable solely to payments in FY 2001 and the 
payment increases resulting for FY 2001 are not taken into account in 
developing payments for future fiscal years.
    As directed by the special rule in section 301(b) of Public Law 
106-554, any discharges occurring on or after October 1, 2000, and 
before April 1, 2001, are paid in accordance with the standardized 
amounts set forth in the FY 2001 hospital inpatient prospective payment 
system final rule published in the August 1, 2000 Federal Register (65 
FR 47126). These rates were calculated using the market basket 
percentage increase of 3.4 percent minus 1.1 percentage points, for a 
2.3 percent increase (see 65 FR 47112), as directed by section 
1886(b)(3)(B)(i) of the Act prior to the passage of Public Law 106-554.
    To implement the special rule under section 301(b) of Public Law 
106-554, in the June 13 interim final rule with comment period, we 
recomputed the standardized amounts effective for discharges occurring 
on or after April 1, 2001. That is, we replaced the update factor of 
2.3 percent applied to the standardized amounts in the August 1, 2000 
final rule, with the update factor of 4.5 percent (the market basket 
percentage increase plus 1.1 percentage points, or 3.4 plus 1.1 
percentage points).

----------------------------------------------------------------------------------------------------------------
                                                                  Large urban areas            Other areas
                                                             ---------------------------------------------------
                                                                 Labor-     Nonlabor-      Labor-     Nonlabor-
                                                                related      related      related      related
----------------------------------------------------------------------------------------------------------------
National....................................................    $2,925.82    $1,189.26    $2,879.51    $1,170.43
National PR.................................................     2,900.64     1,179.02     2,900.64     1,179.02
Puerto Rico.................................................     1,402.79       564.66     1,380.58       555.72
SCHs........................................................     2,895.02     1,176.74     2,849.20     1,158.11
----------------------------------------------------------------------------------------------------------------

A. Budget Neutrality

    Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning in 
FY 1991, the annual DRG reclassification and recalibration of the 
relative weights must be made in a manner that ensures that aggregate 
payments to hospitals are projected to be the same as those that would 
have been made without such adjustments. Section 1886(d)(3)(E) of the 
Act requires us to update the hospital wage index on an annual basis 
beginning October 1, 1993. This provision also requires us to make any 
updates or adjustments to the wage index in a manner that ensures that 
aggregate payments to hospitals are projected to be the same as those 
that would have been made without the change in the wage index.
    Finally, under section 1886(d)(8)(D) of the Act, the Secretary is 
required to adjust the standardized amounts so as to ensure that final 
aggregate payments under the prospective payment system are projected 
to equal the aggregate prospective payments that would have been made 
absent the geographic reclassification provisions of sections 
1886(d)(8)(B) and (C) and 1886(d)(10) of the Act.
    The distributive effects on hospital payments of the IME and DSH 
changes also included in Public Law 106-554 required us to recalculate 
the budget neutrality factors that are required by section 
1886(d)(8)(D) of the Act.
    As we stated in the June 13, 2001 interim final rule with comment 
period, the budget neutrality factors that were used to establish the 
standardized amounts effective for discharges occurring on or after 
October 1, 2000 were: 0.997225 for the DRG reclassification and 
recalibration and updated wage index (65 FR 47112); and 0.993187 for 
geographic reclassification (65 FR 47113). Using the same methodology 
that was used to calculate the budget neutrality factors in the August 
1, 2000 final rule, the corresponding budget neutrality factors for the 
standardized amounts effective for discharges occurring on or after 
April 1, 2001 and before October 1, 2001 are 0.997122 and 0.993279. The 
FY 2001 budget neutrality factor for Puerto Rico did not change. 
Therefore, the budget neutrality factor for Puerto Rico as published in 
the August 1, 2000 Federal Register (65 FR 47112) remained in effect 
for discharges occurring on or after April 1, 2001 and before October 
1, 2001.

B. Outliers

    In accordance with section 1886(d)(3)(B) of the Act, which directs 
the Secretary to adjust the national standardized amounts to account 
for the estimated proportion of total payments made to outlier cases, 
the fixed-loss outlier threshold was also revised as a result of the 
change made by Public Law 106-554 to the update factor for the 
operating standardized amounts. For discharges occurring on or after 
April 1, 2001 and before October 1, 2001, we established a fixed-loss 
cost outlier threshold equal to the prospective payment rate for the 
DRG, plus IME and

[[Page 39946]]

DSH payments, plus $16,350 ($14,940 for hospitals that have not yet 
entered the prospective payment system for capital-related costs). (In 
the June 13, 2001 interim final rule with comment period, the fixed 
loss amount was stated as $16,500. This was an error. The correct 
amount is $16,350. This is the amount that has been applied to 
discharges since April 1, 2001, in the PRICER software used to 
determine payments.) In determining the outlier threshold, we used the 
same methodology employed to determine the outlier threshold for FY 
2001 (65 FR 47113 through 47114). Outlier payments for discharges 
occurring on or after October 1, 2000 and before April 1, 2001, will be 
determined in accordance with the standardized amounts and outlier 
thresholds set forth in the FY 2001 final rule published in the August 
1, 2000 Federal Register (65 FR 47113).
    Although the market basket percentage used to update SCHs was not 
revised by Public Law 106-554, the standardized amounts applied to 
these hospitals for discharges occurring on or after April 1, 2001 and 
before October 1, 2001 also increase slightly. This increase in SCH 
rates is due to the budget neutrality factors effective for this 
portion of the fiscal year.
    For discharges occurring on or after April 1, 2001 and before 
October 1, 2001, the outlier adjustment factors are as follows:

------------------------------------------------------------------------
                                                 Operating     Capital
                                               standardized    federal
                                                  amounts        rate
------------------------------------------------------------------------
National.....................................      0.948929     0.937854
Puerto Rico..................................      0.973671     0.967355
------------------------------------------------------------------------

III. Changes to Payment Rates for Inpatient Capital-Related Costs 
for FY 2002

    The prospective payment system for hospital inpatient capital-
related costs was implemented for cost reporting periods beginning on 
or after October 1, 1991. Effective with that cost reporting period and 
during a 10-year transition period extending through FY 2001, hospital 
inpatient capital-related costs are paid on the basis of an increasing 
proportion of the capital prospective payment system Federal rate and a 
decreasing proportion of a hospital's historical costs for capital.
    The basic methodology for determining Federal capital prospective 
rates is set forth at Secs. 412.308 through 412.352. Below we discuss 
the factors that we used to determine the capital Federal rate rate and 
the hospital-specific rates for FY 2002. The rates, which will be 
effective for discharges occurring on or after October 1, 2001. As we 
stated in section V. of the preamble of this final rule, we are no 
longer determining an update to the capital hospital-specific rate, 
since FY 2001 is the last year of the 10-year transition period, and 
beginning in FY 2002 all hospitals (except ``new'' hospitals under 
Sec. 412.324(b)) will be paid based on 100 percent of the capital 
Federal rate.
    For FY 1992, we computed the standard Federal payment rate for 
capital-related costs under the prospective payment system by updating 
the FY 1989 Medicare inpatient capital cost per case by an actuarial 
estimate of the increase in Medicare inpatient capital costs per case. 
Each year after FY 1992, we update the standard Federal rate, as 
provided in Sec. 412.308(c)(1), to account for capital input price 
increases and other factors. Also, Sec. 412.308(c)(2) provides that the 
Federal rate is adjusted annually by a factor equal to the estimated 
proportion of outlier payments under the Federal rate to total capital 
payments under the Federal rate. In addition, Sec. 412.308(c)(3) 
requires that the Federal rate be reduced by an adjustment factor equal 
to the estimated proportion of payments for (regular and special) 
exceptions under Sec. 412.348. Furthermore, Sec. 412.308(c)(4)(ii) 
requires that the Federal rate be adjusted so that the annual DRG 
reclassification and the recalibration of DRG weights and changes in 
the geographic adjustment factor are budget neutral. For FYs 1992 
through 1995, Sec. 412.352 required that the Federal rate also be 
adjusted by a budget neutrality factor so that aggregate payments for 
inpatient hospital capital costs were projected to equal 90 percent of 
the payments that would have been made for capital-related costs on a 
reasonable cost basis during the fiscal year. That provision expired in 
FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to 
the rate that was made in FY 1994, and Sec. 412.308(b)(3) describes the 
0.28 percent reduction to the rate made in FY 1996 as a result of the 
revised policy of paying for transfers. In the FY 1998 final rule with 
comment period (62 FR 45966), we implemented section 4402 of Public Law 
105-33, which requires that for discharges occurring on or after 
October 1, 1997, and before October 1, 2002, the unadjusted standard 
Federal rate is reduced by 17.78 percent. A small part of that 
reduction will be restored effective October 1, 2002.
    To determine the appropriate budget neutrality adjustment factor 
and the regular exceptions payment adjustment, we developed a dynamic 
model of Medicare inpatient capital-related costs, that is, a model 
that projects changes in Medicare inpatient capital-related costs over 
time. With the expiration of the budget neutrality provision, the model 
is still used to estimate the regular exceptions payment adjustment and 
other factors. The model and its application are described in greater 
detail in Appendix B of this final rule.
    In accordance with section 1886(d)(9)(A) of the Act, under the 
prospective payment system for inpatient operating costs, hospitals 
located in Puerto Rico are paid for operating costs under a special 
payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a 
blended rate that consisted of 75 percent of the applicable 
standardized amount specific to Puerto Rico hospitals and 25 percent of 
the applicable national average standardized amount. However, effective 
October 1, 1997, as a result of section 4406 of Public Law 105-33, 
operating payments to hospitals in Puerto Rico are based on a blend of 
50 percent of the applicable standardized amount specific to Puerto 
Rico hospitals and 50 percent of the applicable national average 
standardized amount. In conjunction with this change to the operating 
blend percentage, effective with discharges on or after October 1, 
1997, we compute capital payments to hospitals in Puerto Rico based on 
a blend of 50 percent of the Puerto Rico rate and 50 percent of the 
Federal rate.
    Section 412.374 provides for the use of this blended payment system 
for payments to Puerto Rico hospitals under the prospective payment 
system for inpatient capital-related costs. Accordingly, for capital-
related costs, we compute a separate payment rate specific to Puerto 
Rico hospitals using the same methodology used to compute the national 
Federal rate for capital.

A. Determination of Federal Inpatient Capital-Related Prospective 
Payment Rate Update

    In the August 1, 2000 final rule (65 FR 47122), we established a 
Federal rate of $382.03 for FY 2001. In the June 13, 2001 interim final 
rule with comment, as a result of implementing section 301(b) of Public 
Law 106-554, we established a Federal rate of $380.85 for discharges 
occurring on or after April 1, 2001 and before October 1, 2001 (66 FR 
32180). (See section V.E. of the preamble and section III.A.5 of this 
Addendum for a fuller discussion of the provisions of section 301(b) of 
Public Law 106-554.) In accordance with section 547 of Public Law 106-
554, the special payment increases provided by Public Law 106-554 
effective between

[[Page 39947]]

April and October 2001 do not apply for discharges occurring after FY 
2001 and are not taken into account in determining the payment rates in 
subsequent years. Thus, the adjustments and rates published in the 
August 1, 2000 final rule were used in determining the FY 2002 capital 
rates. As a result of the changes to the factors used to establish the 
Federal rate in this addendum, the FY 2002 Federal rate is $390.74.
    In the discussion that follows, we explain the factors that were 
used to determine the FY 2002 Federal rate. In particular, we explain 
why the FY 2002 Federal rate has increased 2.28 percent compared to the 
FY 2001 Federal rate (published in the August 1, 2000 final rule (65 FR 
47122)). We also estimate aggregate capital payments will increase by 
4.27 percent during this same period. This increase is primarily due to 
the increase in the number of hospital admissions and the increase in 
case-mix. This increase in capital payments is slightly less than last 
year (5.48 percent) because with the end of the transition period the 
remaining hold harmless hospitals receiving ``cost-based'' payments 
will begin being paid based on 100 percent of the Federal rate.
    Total payments to hospitals under the prospective payment system 
are relatively unaffected by changes in the capital prospective 
payments. Since capital payments constitute about 10 percent of 
hospital payments, a 1 percent change in the capital Federal rate 
yields only about 0.1 percent change in actual payments to hospitals. 
Aggregate payments under the capital prospective payment system are 
estimated to increase in FY 2002 compared to FY 2001.
1. Standard Federal Rate Update
    Under Sec. 412.308(c)(1), the standard Federal rate is updated on 
the basis of an analytical framework that takes into account changes in 
a capital input price index and other factors. The update framework 
consists of a capital input price index (CIPI) and several policy 
adjustment factors. Specifically, we have adjusted the projected CIPI 
rate of increase as appropriate each year for case-mix index-related 
changes, for intensity, and for errors in previous CIPI forecasts. The 
proposed rule reflected an update factor for FY 2002 under that 
framework of 1.1 percent, based on data available at that time. Under 
the update framework, the final update factor for FY 2002 is 1.3 
percent. This update factor is based on a projected 0.7 percent 
increase in the CIPI, a 0.3 percent adjustment for intensity, a 0.0 
percent adjustment for case-mix, a 0.0 percent adjustment for the FY 
2000 DRG reclassification and recalibration, and a forecast error 
correction of 0.3 percent. We explain the basis for the FY 2002 CIPI 
projection in section II.C. of this Addendum. Below we describe the 
policy adjustments that have been applied.
    The case-mix index is the measure of the average DRG weight for 
cases paid under the prospective payment system. Because the DRG weight 
determines the prospective payment for each case, any percentage 
increase in the case-mix index corresponds to an equal percentage 
increase in hospital payments.
    The case-mix index can change for any of several reasons:
     The average resource use of Medicare patients changes 
(``real'' case-mix change);
     Changes in hospital coding of patient records result in 
higher weight DRG assignments (``coding effects''); and
     The annual DRG reclassification and recalibration changes 
may not be budget neutral (``reclassification effect'').
    We define real case-mix change as actual changes in the mix (and 
resource requirements) of Medicare patients as opposed to changes in 
coding behavior that result in assignment of cases to higher weighted 
DRGs but do not reflect higher resource requirements. In the update 
framework for the prospective payment system for operating costs, we 
adjust the update upwards to allow for real case-mix change, but remove 
the effects of coding changes on the case-mix index. We also remove the 
effect on total payments of prior changes to the DRG classifications 
and relative weights, in order to retain budget neutrality for all 
case-mix index-related changes other than patient severity. (For 
example, we adjusted for the effects of the FY 2000 DRG 
reclassification and recalibration as part of our FY 2002 update 
recommendation.) We have adopted this case-mix index adjustment in the 
capital update framework as well.
    For FY 2002, we are projecting a 1.0 percent increase in the case-
mix index. We estimate that real case-mix increase will equal 1.0 
percent in FY 2002. Therefore, the net adjustment for case-mix change 
in FY 2002 is 0.0 percentage points.
    We estimate that FY 2000 DRG reclassification and recalibration 
will result in a 0.0 percent change in the case-mix when compared with 
the case-mix index that would have resulted if we had not made the 
reclassification and recalibration changes to the DRGs. Therefore, we 
are making a 0.0 percent adjustment for DRG reclassification and 
recalibration in the update recommendation for FY 2002.
    The capital update framework contains an adjustment for forecast 
error. The input price index forecast is based on historical trends and 
relationships ascertainable at the time the update factor is 
established for the upcoming year. In any given year, there may be 
unanticipated price fluctuations that may result in differences between 
the actual increase in prices and the forecast used in calculating the 
update factors. In setting a prospective payment rate under the 
framework, we make an adjustment for forecast error only if our 
estimate of the change in the capital input price index for any year is 
off by 0.25 percentage points or more. There is a 2-year lag between 
the forecast and the measurement of the forecast error. A forecast 
error of 0.3 percentage points was calculated for the FY 2000 update. 
That is, current historical data indicate that the forecasted FY 2000 
CIPI used in calculating the FY 2000 update factor (0.6 percent) 
understatethe actual realized price increases (0.9 percent) by 0.3 
percentage points. This under-prediction was due to prices from 
municipal bond yields declining slower than expected. Therefore, we are 
making a 0.0 3 percent adjustment for forecast error in the update for 
FY 2002.
    Under the capital prospective payment system framework, we also 
make an adjustment for changes in intensity. We calculate this 
adjustment using the same methodology and data as in the framework for 
the operating prospective payment system. The intensity factor for the 
operating update framework reflects how hospital services are utilized 
to produce the final product, that is, the discharge. This component 
accounts for changes in the use of quality-enhancing services, changes 
in within-DRG severity, and expected modification of practice patterns 
to remove cost-ineffective services.
    We calculate case-mix constant intensity as the change in total 
charges per admission, adjusted for price level changes (the CPI for 
hospital and related services), and changes in real case-mix. The use 
of total charges in the calculation of the proposed intensity factor 
makes it a total intensity factor, that is, charges for capital 
services are already built into the calculation of the factor. 
Therefore, we have incorporated the intensity adjustment from the 
operating update framework into the capital update framework. Without 
reliable estimates of the proportions of the overall annual intensity 
increases that are due, respectively, to ineffective practice patterns 
and to the combination

[[Page 39948]]

of quality-enhancing new technologies and within-DRG complexity, we 
assume, as in the revised operating update framework, that one-half of 
the annual increase is due to each of these factors. The capital update 
framework thus provides an add-on to the input price index rate of 
increase of one-half of the estimated annual increase in intensity to 
allow for within-DRG severity increases and the adoption of quality-
enhancing technology.
    For FY 2002, we have developed a Medicare-specific intensity 
measure based on a 5-year average, using FY 1996 through 2000 data. In 
determining case-mix constant intensity, we found that observed case-
mix increase was 1.6 percent in FY 1996, 0.3 percent in FY 1997, -0.4 
percent in FY 1998, and -0.3 in FY 1999, and -0.7 percent in FY 2000. 
Since we found an increase in case-mix of 1.6 for FY 1996, which was 
outside of the range of 1.0 to 1.4 percent, we estimate that real case-
mix increase was 1.0 to 1.4 percent for that year. The estimate of 1.0 
to 1.4 percent is supported by past studies of case-mix change by the 
RAND Corporation. The most recent study was ``Has DRG Creep Crept Up? 
Decomposing the Case Mix Index Change Between 1987 and 1988'' by G. M. 
Carter, J. P. Newhouse, and D. A. Relles, R-4098-HCFA/ProPAC (1991). 
The study suggested that real case-mix change was not dependent on 
total change, but was usually a fairly steady 1.0 to 1.4 percent per 
year. We use 1.4 percent as the upper bound because the RAND study did 
not take into account that hospitals may have induced doctors to 
document medical records more completely in order to improve payment. 
Following that study, we consider up to 1.4 percent of observed case-
mix change as real for FY 1996 through FY 2000. Based on this analysis, 
we believe that all of the observed case-mix increase for FY 1997, FY 
1998, and FY 1999, and FY 2000 is real. The increases for FY 1996 was 
in excess of our estimate of real case-mix increase.
    We calculate case-mix constant intensity as the change in total 
charges per admission, adjusted for price level changes (the CPI for 
hospital and related services), and changes in real case-mix. Based 
upon an upper limit of 1.0 percent real case-mix increase, we estimate 
that case-mix constant intensity increased by an average 0.3 percent 
during FYs 1996 through 2000, for a cumulative increase of 1.4 percent, 
given estimates of real case-mix of -1.0 percent for FY 1996, 0.3 
percent for FY 1997, -0.4 for FY 1998, and -0.3 for FY 1999, and -0.7 
percent for FY 2000. Based upon an upper limit of 1.4 percent real 
case-mix increase, we estimate that case-mix constant intensity 
declined increase by an average 0.2 percent during FYs 1996 through 
2000, for a cumulative increase of 1.2 percent, given that real case-
mix increase was 1.4 percent for FY 1996, 0.3 percent for FY 1997, -0.4 
for FY 1998, -0.3 for FY 1999, and -0.7 percent for FY 2000. Since we 
estimate that intensity has increased during that period, we are 
recommending a 0.3 percent intensity adjustment for FY 2002.
2. Outlier Payment Adjustment Factor
    Section 412.312(c) establishes a unified outlier methodology for 
inpatient operating and inpatient capital-related costs. A single set 
of thresholds is used to identify outlier cases for both inpatient 
operating and inpatient capital-related payments. Section 412.308(c)(2) 
provides that the standard Federal rate for inpatient capital-related 
costs be reduced by an adjustment factor equal to the estimated 
proportion of capital-related outlier payments to total inpatient 
capital-related prospective payment system payments. The outlier 
thresholds are set so that operating outlier payments are projected to 
be 5.1 percent of total operating DRG payments.
    In the August 1, 2000 final rule, we estimated that outlier 
payments for capital in FY 2001 would equal 5.91 percent of inpatient 
capital-related payments based on the Federal rate (65 FR 47121). 
Accordingly, we applied an outlier adjustment factor of 0.9409 to the 
Federal rate. Based on the thresholds as set forth in section II.A.4.c. 
of this Addendum, we estimate that outlier payments for capital will 
equal 5.76 percent of inpatient capital-related payments based on the 
Federal rate in FY 2002. Therefore, we are establishing an outlier 
adjustment factor of 0.9424 to the Federal rate. Thus, the projected 
percentage of capital outlier payments to total capital standard 
payments for FY 2002 is lower than the percentage for FY 2001.
    The outlier reduction factors are not built permanently into the 
rates; that is, they are not applied cumulatively in determining the 
Federal rate. As explained previously, in accordance with section 547 
of Public Law 106-554, the FY 2002 rates are based on the FY 2001 
adjustments and rates published in the August 1, 2000 final rule (65 FR 
47122). Therefore, the net change in the outlier adjustment to the 
Federal rate for FY 2002 is 1.0016 (0.9424/0.9409). The outlier 
adjustment increases the FY 2002 Federal rate by 0.16 percent compared 
with the FY 2001 outlier adjustment.
3. Budget Neutrality Adjustment Factor for Changes in DRG 
Classifications and Weights and the Geographic Adjustment Factor
    Section 412.308(c)(4)(ii) requires that the Federal rate be 
adjusted so that aggregate payments for the fiscal year based on the 
Federal rate after any changes resulting from the annual DRG 
reclassification and recalibration and changes in the geographic 
adjustment factor (GAF) are projected to equal aggregate payments that 
would have been made on the basis of the Federal rate without such 
changes. We use the actuarial model, described in Appendix B of this 
final rule, to estimate the aggregate payments that would have been 
made on the basis of the Federal rate without changes in the DRG 
classifications and weights and in the GAF. We also use the model to 
estimate aggregate payments that would be made on the basis of the 
Federal rate as a result of those changes. We then use these figures to 
compute the adjustment required to maintain budget neutrality for 
changes in DRG weights and in the GAF.
    For FY 2001, we calculated a GAF/DRG budget neutrality factor of 
0.9979. In the proposed rule for FY 2002, we proposed a GAF/DRG budget 
neutrality factor of 0.9913. In this final rule, based on calculations 
using updated data, we are applying a factor of 0.9934. The GAF/DRG 
budget neutrality factors are built permanently into the rates; that 
is, they are applied cumulatively in determining the Federal rate. This 
follows from the requirement that estimated aggregate payments each 
year be no more or less than they would have been in the absence of the 
annual DRG reclassification and recalibration and changes in the GAF. 
As explained previously, in accordance with section 547 of Public Law 
106-554, the FY 2002 adjustments and rates are based on the FY 2001 
adjustment and rates published in the August 1, 2000 final rule (65 FR 
47122). The incremental change in the adjustment from FY 2001 to FY 
2002 is 0.9934. The cumulative change in the rate due to this 
adjustment is 0.9927 (the product of the incremental factors for FY 
1993, FY 1994, FY 1995, FY 1996, FY 1997, FY 1998, FY 1999, FY 2000, FY 
2001 and the incremental factor for FY 2002:0.9980  x 1.0053  x 0.9998 
x 0.9994  x 0.9987  x 0.9989  x 1.0028  x 0.9985  x 0.9979  x 0.9934 
=0.9927).
    This factor accounts for DRG reclassifications and recalibration 
and for changes in the GAF. It also

[[Page 39949]]

incorporates the effects on the GAF of FY 2002 geographic 
reclassification decisions made by the MGCRB compared to FY 2001 
decisions. However, it does not account for changes in payments due to 
changes in the DSH and IME adjustment factors or in the large urban 
add-on.
4. Exceptions Payment Adjustment Factor
    Section 412.308(c)(3) requires that the standard Federal rate for 
inpatient capital-related costs be reduced by an adjustment factor 
equal to the estimated proportion of additional payments for exceptions 
under Sec. 412.348 relative to total capital payments payments under 
the hospital-specific rate and Federal rate. We use the model 
originally developed for determining the budget neutrality adjustment 
factor to determine the regular exceptions payment adjustment factor. 
We describe that model in Appendix B to this final rule. An adjustment 
for regular exceptions is necessary for determining the FY 2002 rates 
because we will continue to pay regular exceptions for cost reporting 
periods beginning before October 1, 2001 but ending in FY 2002, in 
accordance with Sec. 412.312(c)(3). In FY 2003 and later, no payments 
will be made under the regular exceptions provision, and then we will 
only compute a budget neutrality adjustment under Sec. 412.348(d) for 
special exceptions. We describe the methodology to determine the 
special exceptions adjustment in section V.D. of this final rule. For 
FY 2002, the exceptions adjustment is a combination of the adjustment 
that would be made under the regular exceptions provision and under the 
special exceptions provision under Sec. 412.348(g).
    For FY 2001, we estimated that exceptions payments would equal 2.15 
percent of aggregate payments based on the Federal rate. Therefore, we 
applied an exceptions reduction factor of 0.9785 (1--;0.0215) in 
determining the Federal rate. In the May 4, 2001 proposed rule, we 
estimated that regular exceptions payments for FY 2002 would equal 0.63 
percent of aggregate payments based on the Federal rate, we estimated 
that special exceptions payments for FY 2002 would equal 0.12 percent 
of aggregate payments based on the Federal rate. Therefore, we 
estimated that total exceptions payments for FY 2002 would equal 0.75 
percent (0.63 + 0.12 = 0.75) of aggregate payments based on the Federal 
rate, and we proposed an exceptions payment reduction factor of 0.9925 
(1--;0.0075) to the Federal rate for FY 2002. The proposed exceptions 
reduction factor for FY 2002 was 1.43 percent higher than the factor 
for FY 2001 published in the August 1, 2000 final rule.
    For this final rule, based on updated data, we estimate that 
regular exceptions payments for FY 2002 will equal 0.59 percent of 
aggregate payments based on the Federal rate, and we estimate that 
special exceptions payments for FY 2002 will equal 0.12 percent of 
aggregate payments based on the Federal rate. We estimate that total 
exceptions payments for FY 2002 will be 0.71 percent (0.59 + 0.12 = 
0.71). Thus, the FY 2002 exceptions payment reduction factor is 0.9929 
(1--0.0071). The exceptions reduction factor for FY 2002 is 1.47 
percent higher than the factor for FY 2001 published in the August 1, 
2000 final rule. This increase is primarily due to the expiration of 
the regular exceptions provision and the narrowly defined nature of the 
special exceptions policy.
    The exceptions reduction factors are not built permanently into the 
rates; that is, the factors are not applied cumulatively in determining 
the Federal rate. As explained previously, in accordance with section 
547 of Public Law 106-554, the FY 2002 adjustments and rates are based 
on the FY 2001 adjustments and rates published in the August 1, 2000 
final rule (65 FR 47122). Therefore, the net adjustment to the FY 2002 
Federal rate is 0.9929/0.9785, or 1.0147.
5. Standard Capital Federal Rate for FY 2002
    For FY 2001, the capital Federal rate was $382.03 for discharges 
occurring between October 1, 2000 and April 1, 2001. As a result of 
implementing section 301(b) of Public Law 106-554, for discharges 
occurring from April to October 2001, the capital Federal rate was 
$380.85. However, as explained previously, in accordance with section 
547 of Public Law 106-554, the FY 2002 adjustments and rates are based 
on the FY 2001 adjustments and rates published in the August 1, 2000 
final rule (65 FR 47122). As a result of changes we are making to the 
factors used to establish the Federal rate, in this final rule we are 
establishing the capital Federal rate for FY 2002 of $390.74. The 
Federal rate for FY 2002 was calculated as follows:
     The FY 2002 update factor is 1.0130; that is, the update 
is 1.30 percent.
     The FY 2002 budget neutrality adjustment factor that is 
applied to the standard Federal payment rate for changes in the DRG 
relative weights and in the GAF is 0.9934.
     The FY 2002 outlier adjustment factor is 0.94214.
     The FY 2002 (regular and special) exceptions payments 
adjustment factor is 0.9929.
    Since the Federal rate has already been adjusted for differences in 
case-mix, wages, cost-of-living, indirect medical education costs, and 
payments to hospitals serving a disproportionate share of low-income 
patients, we have made no additional adjustments in the standard 
Federal rate for these factors, other than the budget neutrality factor 
for changes in the DRG relative weights and the GAF.
    We are providing a chart that shows how each of the factors and 
adjustments for FY 2002 affected the computation of the FY 2002 Federal 
rate in comparison to the FY 2001 Federal rate. The FY 2002 update 
factor has the effect of increasing the Federal rate by 1.30 percent 
compared to the FY 2001 rate published in the August 1, 2000 final 
rule, while the geographic and DRG budget neutrality factor has the 
effect of decreasing the Federal rate by 0.66 percent. The FY 2002 
outlier adjustment factor has the effect of increasing the Federal rate 
by 0.16 percent compared to the FY 2001 rate published in the August 1, 
2000 final rule. The FY 2002 (regular and special) exceptions reduction 
factor has the effect of increasing the Federal rate by 1.47 percent 
compared to the exceptions reduction for FY 2001. The combined effect 
of all the proposed changes is to increase the Federal rate by 2.28 
percent compared to the Federal rate for FY 2001.

              Comparison of Factors and Adjustments: FY 2001 Federal Rate and FY 2002 Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                                                                       Percent
                                                                FY 2001      FY 2002       Change       change
----------------------------------------------------------------------------------------------------------------
Update factor\1\............................................       1.0090       1.0130       1.0130         1.30
GAF/DRG Adjustment Factor\1\................................       0.9979       0.9934       0.9934        -0.66
Outlier Adjustment Factor\2\................................       0.9409       0.9424       1.0016         0.16

[[Page 39950]]

 
Exceptions Adjustment Factor\2\.............................       0.9785       0.9929       1.0147         1.47
Federal Rate................................................      $382.03      $390.74       1.0228         2.28
----------------------------------------------------------------------------------------------------------------
\1\ The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for
  example, the incremental change from FY 2000 to FY 2001 resulting from the application of the 0.9934 GAF/DRG
  budget neutrality factor for FY 2001 is 0.9934.
\2\ The outlier reduction factor and the exceptions reduction factor are not built permanently into the rates;
  that is, these factors are not applied cumulatively in determining the rates. Thus, for example, the net
  change resulting from the application of the FY 2001 outlier reduction factor is 0.9424/0.9409, or 1.0016.

    As stated previously in this section, the FY 2002 Federal rate has 
increased 2.28 percent compared to the FY 2001 capital Federal rate as 
a result of the FY 2002 factors and adjustments applied to the capital 
Federal rate. Specifically, the capital update factor increased the 
capital Federal rate 1.30 percent over FY 2001. The exceptions 
reduction factor increased 1.47 percent from 0.9875 to 0.9929 for FY 
2002, which results in an increase to the capital Federal rate for FY 
2002. Also, the outlier adjustment factor increased 0.16 percent from 
0.9409 for FY 2001 to 0.9424 for FY 2002, which results in an increase 
to the capital Federal rate in FY 2002 compared to FY 2001. The GAF/DRG 
adjustment factor decreased 0.66 percent from 0.9979 for FY 2001 to 
0.9934 for FY 2002, which results in a decrease the capital Federal 
rate for FY 2002 compared to FY 2001. The effect of all these changes 
is a 2.28 percent increase in the FY 2002 capital Federal rate compared 
to FY 2001.
    We are also providing a chart that shows how the final FY 2002 
capital Federal rate differs from the proposed FY 2002 capital Federal 
rate.

       Comparison of Factors and Adjustments: FY 2002 Proposed Federal Rate and FY 2002 Final Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                              Proposed FY    Final FY                  Percent
                                                                  2002         2002        Change       change
----------------------------------------------------------------------------------------------------------------
Update factor...............................................       1.0110       1.0130       1.0020         0.20
GAF/DRG Adjustment Factor...................................       0.9913       0.9934       1.0021         0.21
Outlier Adjustment Factor...................................       0.9426       0.9424       0.9998        -0.02
Exceptions Adjustment Factor................................       0.9925       0.9929       1.0004         0.04
Federal Rate................................................      $389.09      $390.74       1.0042         0.42
----------------------------------------------------------------------------------------------------------------

6. Special Rate for Puerto Rico Hospitals
    As explained at the beginning of section II.D. of this Addendum, 
hospitals in Puerto Rico are paid based on 50 percent of the Puerto 
Rico rate and 50 percent of the Federal rate. The Puerto Rico rate is 
derived from the costs of Puerto Rico hospitals only, while the Federal 
rate is derived from the costs of all acute care hospitals 
participating in the prospective payment system (including Puerto 
Rico). To adjust hospitals' capital payments for geographic variations 
in capital costs, we apply a GAF to both portions of the blended rate. 
The GAF is calculated using the operating prospective payment system 
wage index and varies, depending on the MSA or rural area in which the 
hospital is located. We use the Puerto Rico wage index to determine the 
GAF for the Puerto Rico part of the capital-blended rate and the 
national wage index to determine the GAF for the national part of the 
blended rate.
    Because we implemented a separate GAF for Puerto Rico in FY 1998, 
we also apply separate budget neutrality adjustments for the national 
GAF and for the Puerto Rico GAF. However, we apply the same budget 
neutrality factor for DRG reclassifications and recalibration 
nationally and for Puerto Rico. The Puerto Rico GAF budget neutrality 
factor is 0.9899, while the DRG adjustment is 0.9967, for a combined 
cumulative adjustment of 0.9866.
    In computing the payment for a particular Puerto Rico hospital, the 
Puerto Rico portion of the rate (50 percent) is multiplied by the 
Puerto Rico-specific GAF for the MSA in which the hospital is located, 
and the national portion of the rate (50 percent) is multiplied by the 
national GAF for the MSA in which the hospital is located (which is 
computed from national data for all hospitals in the United States and 
Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to 
the Puerto Rico rate as a result of Public Law 105-33.
    For FY 2001, before application of the GAF, the special rate for 
Puerto Rico hospitals was $185.06. As explained previously, in 
accordance with section 547 of Public Law 106-554, the FY 2002 
adjustments and rates are based on the FY 2001 rates published in the 
August 1, 2000 final rule. With the changes we proposed to the factors 
used to determine the rate, the proposed FY 2002 special rate for 
Puerto Rico was $188.67. In this final rule, based on the final 
factors, the FY 2002 capital rate for Puerto Rico is $187.73.
7. Changes in the Capital Prospective Payment System Rates for FY 2001
    In the June 13, 2001 interim final rule with comment period, we 
implemented section 301(b) of Public Law 106-554 (66 FR 32180).
    Section 301(b) of Public Law 106-554 provided a special rule to 
implement the full market basket update to inpatient hospital operating 
prospective payment rates for FY 2001. Under this special rule, for 
discharges occurring on or after October 1, 2000 and before April 1, 
2001, the update factor for inpatient prospective payment system 
hospitals (other than SCHs) is equal to the market basket percentage 
increase minus 1.1 percentage points. For discharges occurring on or 
after April 1, 2001 and before October 1, 2001, the update factor for 
the payment rates for inpatient prospective payment system hospitals 
(other than SCHs) is equal to the market basket percentage increase 
plus 1.1 percentage points. Section 547 of Public Law 106-554 makes 
this special rule applicable solely to payments in FY 2001, and the 
payment increases resulting for FY 2001 are not taken into

[[Page 39951]]

account in developing payments for future fiscal years.
    As directed by the special rule in section 301(b) of Public Law 
106-554, any discharges occurring on or after October 1, 2000, and 
before April 1, 2001, will be paid in accordance with the standardized 
amounts set forth in the FY 2001 hospital inpatient prospective payment 
system final rule published in the August 1, 2000 Federal Register (65 
FR 47126). These rates were calculated using the market basket 
percentage increase of 3.4 percent minus 1.1 percentage points, for a 
2.3 percent increase (see 65 FR 47112), as directed by section 
1886(b)(3)(B)(i) of the Act, prior to the passage of Public Law 106-
554.
    As stated in the June 13, 2001 interim final rule with comment 
period, to implement the special rule under section 301(b) of Public 
Law 106-554, we recomputed the standardized amounts effective for 
discharges occurring on or after April 1, 2001. That is, we replaced 
the update factor of 2.3 percent applied to the standardized amounts in 
the August 1, 2000 final rule, with the update factor of 4.5 percent 
(the market basket percentage increase plus 1.1 percentage point, or 
3.4 plus 1.1 percentage points).
    As published in the June 13, 2001 interim final rule with comment 
period (66 FR 32180), the revised capital Federal rate for discharges 
occurring on or after April 1 2001, and before October 1, 2001, are 
shown in the table below.

                       Final FY 2001 Capital Rates
              [Effective April 1, 2001 to October 1, 2001]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
National Rate................................................    $380.85
Puerto Rico Rate.............................................    $184.61
------------------------------------------------------------------------

    Section 1886(d)(3)(B) of the Act directs the Secretary to adjust 
the inpatient operating national standardized amounts to account for 
the estimated proportion of operating DRG payments made to payments in 
outlier cases. Accordingly, as a result of this change to the update to 
the operating standardized amounts for discharges occurring on or after 
April 1, 2001, and before October 1, 2001, we revised the fixed-loss 
outlier thresholds. The regulations at Sec. 412.312(c) establish a 
unified outlier methodology for inpatient operating and inpatient 
capital-related costs, which utilizes a single set of thresholds to 
identify outlier cases for both inpatient operating and inpatient 
capital prospective payment system payments. Because operating DRG 
payments increased as a result of section 301 of Public Law 106-554, we 
decreased the fixed-loss threshold. The decrease in the outlier 
threshold also results in an increase in the estimated outlier payments 
for capital from 5.91 percent to 6.21 percent. Thus, the capital 
national outlier adjustment factor was revised from 0.9409 (as 
specified in the August 1, 2000 final rule (65 FR 47121)) to 0.9379 (as 
specified in the June 13, 2001 interim final rule with comment period).
    As stated earlier, the basic methodology for determining the 
capital Federal rate is set forth in Secs. 412.308 through 412.352. 
Although the operating update to the standardized amounts was affected 
by section 301 of Public Law 106-554, the standard capital Federal rate 
update remained unchanged (0.9 percent). The exceptions adjustment 
factor was determined based on an estimate of the ratio of exception 
payments to total capital payments. As a result of the fixed-cost 
outlier threshold, which affects total capital payments, in order to 
maintain budget neutrality for exception payments, we revised the 
exception adjustment factor from 0.9785 to 0.9787. The national GAF/DRG 
budget neutrality factor was also revised from 0.9979 to 0.9978. The 
Puerto Rico GAF/DRG budget neutrality factor remained unchanged 
(1.0037). Accordingly, as a result of the revisions to the capital 
outlier reduction factor and the capital exceptions adjustment factor, 
for discharges occurring on or after April 1, 2001, and before October 
1, 2001, the national capital Federal rate was revised from $382.03 (65 
FR 47127) to $380.85 and the Puerto Rico capital rate was revised from 
$185.06 (65 FR 47127) to $184.61.
    In accordance with Sec. 412.328(e), the hospital-specific rate is 
determined using the update factor and the exceptions adjustment 
factor. As a result of revising the exceptions adjustment factor to 
account for the change to the fixed-loss outlier threshold resulting 
from the special payment rule for FY 2001 provided for under section 
301(b) of Public Law 106-554, for discharges occurring on or after 
April 1, 2001, and before October 1, 2001, the cumulative net 
adjustment to the hospital-specific rate was revised from 1.0147 (65 FR 
47124) to 1.0145. For discharges occurring on or after April 1, 2001, 
and before October 1, 2001, the hospital-specific rate was determined 
by multiplying the FY 2000 hospital-specific rate by the cumulative net 
adjustment of 1.0145.
B. Calculation of Inpatient Capital-Related Prospective Payments for FY 
2002
    With the end of the capital prospective payment system transition 
period, all hospitals (except ``new'' hospitals under Sec. 412.324(b)) 
will be paid based on 100 percent of the Federal rate in FY 2002. The 
applicable Federal rate was determined by making adjustments as 
follows:
     For outliers, by dividing the standard Federal rate by the 
outlier reduction factor for that fiscal year; and
     For the payment adjustments applicable to the hospital, by 
multiplying the hospital's GAF, disproportionate share adjustment 
factor, and IME adjustment factor, when appropriate.
    For purposes of calculating payments for each discharge during FY 
2002, the standard Federal rate is adjusted as follows: (Standard 
Federal Rate)  x  (DRG weight)  x  (GAF)  x  (Large Urban Add-on, if 
applicable)  x  (COLA adjustment for hospitals located in Alaska and 
Hawaii)  x  (1 + Disproportionate Share Adjustment Factor + IME 
Adjustment Factor, if applicable). The result is the adjusted Federal 
rate.
    Hospitals also may receive outlier payments for those cases that 
qualifyFY under the thresholds established for each fiscal year. 
Section 412.312(c) provides for a single set of thresholds to identify 
outlier cases for both inpatient operating and inpatient capital-
related payments. The outlier thresholds for FY 2002 are in section 
II.A.4.c. of this Addendum. For FY 2002, a case qualifies as a cost 
outlier if the cost for the case plus the IME and DSH payments is 
greater than the prospective payment rate for the DRG plus $21,025.
    During the capital prospective payment system transition period, a 
hospital also may receive an additional payment under the regular 
exceptions process through its cost reporting period beginning before 
October 1, 2001, but ending in FY 2002 if its total inpatient capital-
related payments are less than a minimum percentage of its allowable 
Medicare inpatient capital-related costs. The minimum payment level is 
established by class of hospital under Sec. 412.348(c). Under 
Sec. 412.348(d), the amount of a regular exceptions payment is 
determined by comparing the cumulative payments made to the hospital 
under the capital prospective payment system to the cumulative minimum 
payment levels applicable to the hospital for each cost reporting 
period subject to that system. Any amount by which the hospital's 
cumulative payments exceed its

[[Page 39952]]

cumulative minimum payment is deducted from the additional payment that 
would otherwise be payable for a cost reporting period.
    An eligible hospital may qualify for a special exception payment 
under Sec. 412.348(g) for up through the 10th year beyond the end of 
the capital transition period if it meets (1) a project need 
requirement described at Sec. 412.348(g)(2), which in the case of 
certain urban hospitals includes an excess capacity test; and (2) a 
project size requirement as described at Sec. 412.348(g)(5). Eligible 
hospitals include sole community hospitals, urban hospitals with at 
least 100 beds that have a DSH patient percentage of at least 20.2 
percent, and hospitals that have a combined Medicare and Medicaid 
inpatient utilization of at least 70 percent. Under Sec. 412.348(g)(8), 
the amount of a special exceptions payment is determined by comparing 
the cumulative payments made to the hospital under the capital 
prospective payment system to the cumulative minimum payment level. 
This amount is offset by (1) any amount by which a hospital's 
cumulative capital payments exceed its cumulative minimum payment 
levels applicable under the regular exceptions process for cost 
reporting periods beginning during which the hospital has been subject 
to the capital prospective payment system; and (2) any amount by which 
a hospital's current year operating and capital payments (excluding 75 
percent of operating DSH payments) exceed its operating and capital 
costs. The minimum payment level is 70 percent for all eligible 
hospitals under Sec. 412.348(g).
    New hospitals, as defined under Sec. 412.300, are exempted from the 
capital prospective payment system for their first 2 years of operation 
and are paid 85 percent of their reasonable costs during that period. A 
new hospital's old capital costs are its allowable costs for capital 
assets that were put in use for patient care on or before the later of 
December 31, 1990, or the last day of the hospital's base year cost 
reporting period, and are subject to the rules pertaining to old 
capital and obligated capital as of the applicable date. Effective with 
the third year of operation through the remainder of the transition 
period, we will pay the hospital under either the fully prospective 
methodology, using the appropriate transition blend in that Federal 
fiscal year, or the hold-harmless methodology. If the hold-harmless 
methodology is applicable, the hold-harmless payment for assets in use 
during the base period would extend for 8 years, even if the hold-
harmless payments extend beyond the normal transition period.

C. Capital Input Price Index

1. Background
    Like the operating input price index, the capital input price index 
(CIPI) is a fixed-weight price index that measures the price changes 
associated with costs during a given year. The CIPI differs from the 
operating input price index in one important aspect--the CIPI reflects 
the vintage nature of capital, which is the acquisition and use of 
capital over time. Capital expenses in any given year are determined by 
the stock of capital in that year (that is, capital that remains on 
hand from all current and prior capital acquisitions). An index 
measuring capital price changes needs to reflect this vintage nature of 
capital. Therefore, the CIPI was developed to capture the vintage 
nature of capital by using a weighted-average of past capital purchase 
prices up to and including the current year.
    Using Medicare cost reports, American Hospital Association (AHA) 
data, and Securities Data Company data, a vintage-weighted price index 
was developed to measure price increases associated with capital 
expenses. We periodically update the base year for the operating and 
capital input prices to reflect the changing composition of inputs for 
operating and capital expenses. Currently, the CIPI is based to FY 1992 
and was last rebased in 1997. The most recent discussion of the cost 
category weights in the CIPI was in the final rule with comment period 
for FY 1998 published on August 29, 1997 (62 FR 46050).
    2. Forecast of the CIPI for Federal Fiscal Year 2002
    We are forecasting the CIPI to increase 0.7 percent for FY 2002. 
This reflects a projected 1.4 percent increase in vintage-weighted 
depreciation prices (building and fixed equipment, and movable 
equipment) and a 3.3 percent increase in other capital expense prices 
in FY 2002, partially offset by a 2.0 percent decline in vintage-
weighted interest rates in FY 2002. The weighted average of these three 
factors produces the 0.7 percent increase for the CIPI as a whole.

IV. Changes to Payment Rates for Excluded Hospitals and Hospital 
Units: Rate-of-Increase Percentages

    The inpatient operating costs of hospitals and hospital units 
excluded from the prospective payment system are subject to rate-of-
increase limits established under the authority of section 1886(b) of 
the Act, which is implemented in regulations at Sec. 413.40. Under 
these limits, a hospital-specific target amount (expressed in terms of 
the inpatient operating cost per discharge) is set for each hospital, 
based on the hospital's own historical cost experience trended forward 
by the applicable rate-of-increase percentages (update factors). In the 
case of a psychiatric hospital or hospital unit, a rehabilitation 
hospital or hospital unit, or a long-term care hospital, the target 
amount may not exceed the updated figure for the 75th percentile of 
target amounts adjusted to take into account differences between 
average wage-related costs in the area of the hospital and the national 
average of such costs within the same class of hospital for hospitals 
and units in the same class (psychiatric, rehabilitation, and long-term 
care) for cost reporting periods ending during FY 1996. The target 
amount is multiplied by the number of Medicare discharges in a 
hospital's cost reporting period, yielding the ceiling on aggregate 
Medicare inpatient operating costs for the cost reporting period.
    Each hospital-specific target amount is adjusted annually, at the 
beginning of each hospital's cost reporting period, by an applicable 
update factor.
    Section 1886(b)(3)(B) of the Act, which is implemented in 
regulations at Sec. 413.40(c)(3)(vii), provides that for cost reporting 
periods beginning on or after October 1, 1998 and before October 1, 
2002, the update factor for a hospital or unit depends on the 
hospital's or hospital unit's costs in relation to the ceiling for the 
most recent cost reporting period for which information is available. 
For hospitals with costs exceeding the ceiling by 10 percent or more, 
the update factor is the market basket increase. For hospitals with 
costs exceeding the ceiling by less than 10 percent, the update factor 
is the market basket minus .25 percent for each percentage point by 
which costs are less than 10 percent over the ceiling. For hospitals 
with costs equal to or less than the ceiling but greater than 66.7 
percent of the ceiling, the update factor is the greater of 0 percent 
or the market basket minus 2.5 percent. For hospitals with costs that 
do not exceed 66.7 percent of the ceiling, the update factor is 0.
    The most recent forecast of the market basket increase for FY 2002 
for hospitals and hospital units excluded from the prospective payment 
system is 3.3 percent. Therefore, the update to a hospital's target 
amount for its cost reporting period beginning in FY 2002 would be 
between 0.8 and 3.3 percent, or 0 percent, depending on the

[[Page 39953]]

hospital's or unit's costs in relation to its rate-of-increase limit.
    In addition, Sec. 413.40(c)(4)(iii) requires that for cost 
reporting periods beginning on or after October 1, 1998, and before 
October 1, 2002, the target amount for each psychiatric hospital or 
hospital unit, rehabilitation hospital or hospital unit, and long-term 
care hospital cannot exceed a cap on the target amounts for hospitals 
in the same class.
    Section 1886(b)(3)(H) of the Act, as amended by section 121 of 
Public Law 106-113, provides for an appropriate wage adjustment to the 
caps on the target amounts for psychiatric hospitals and units, 
rehabilitation hospitals and units, and long-term care hospitals, 
effective for cost reporting periods beginning on or after October 1, 
1999, through September 30, 2002. On August 1, 2000, we published an 
interim final rule with comment period that implemented this provision 
for cost reporting periods beginning on or after October 1, 1999 and 
before October 1, 2000 (65 FR 47026) and a final rule that implemented 
the provision for cost reporting periods beginning on or after October 
1, 2000, and before October 1, 2001 (65 FR 47054). This final rule 
addresses the wage adjustment to the caps for cost reporting periods 
beginning on or after October 1, 2001.
    As discussed in section VI. of the preamble of this final rule, the 
cap on the target amount per discharge is determined by adding the 
hospital's nonlabor-related portion of the national 75th percentile cap 
to its wage-adjusted, labor-related portion of the national 75th 
percentile cap (the labor-related portion of costs equals 0.71553 and 
the nonlabor-related portion of costs equals 0.28447). A hospital's 
wage-adjusted, labor-related portion of the target amount is calculated 
by multiplying the labor-related portion of the national 75th 
percentile cap for the hospital's class by the wage index under the 
hospital inpatient prospective payment system (see Sec. 412.63), 
without taking into account reclassifications under sections 
1886(d)(8)(B) and (d)(10) of the Act.
    As discussed in section VI. of the preamble of this final rule, we 
have made an adjustment to the caps on target amounts for new and 
existing excluded hospitals and units. In calculating the wage-adjusted 
caps on target amounts for new and existing excluded and units for FY 
2001, we inadvertently made an error. In wage neutralizing FY 1996 
target amounts, we used the FY 2000 hospital inpatient prospective 
payment system wage index published in Tables 4A and 4B of the July 30, 
1999 final rule (64 FR 41585 through 41593), which is based on wage 
data after taking into account geographic reclassifications under 
section 1886(d)(8) of the Act. We have used pre-reclassified wage data 
in our recalculation of the caps for FY 2002. We recalculated both the 
limits for new excluded hospitals and units and the caps for existing 
excluded hospitals and units, using the same wage index used under the 
prospective payment system for skilled nursing facilities (SNF) as 
shown in Table 7 of the July 30, 1999 SNF final rule (64 FR 41690). We 
do not anticipate a significant impact on overall payments to these 
hospitals and units.
    Section 307(a) of Public Law 106-554 amended section 1886(b)(3) of 
the Act to provide for a 2-percent increase to the wage-adjusted 75th 
percentile cap on the target amount for long-term care hospitals, 
effective for cost reporting periods beginning during FY 2001. This 
provision is applicable to long-term care hospitals that were subject 
to the cap for existing excluded hospitals and units, as specified in 
Sec. 413.40(c).
    In addition to the increase to the cap on the target amounts for 
long-term care hospitals, section 307(a) of Public Law 106-554 amended 
section 1886(b)(3)(A) of the Act to make the section applicable to all 
long-term care hospitals, effective for cost reporting periods 
beginning during FY 2001. This provision requires a revision to the 
determination of each long-term care hospital's FY 2001 target amount 
as specified in Sec. 413.40(c)(4). For cost reporting periods beginning 
during FY 2001, the hospital-specific target amount otherwise 
determined for a long-term care hospital as specified under 
Sec. 413.40(c)(4)(ii) is multiplied by 1.25 (that is, increased by 25 
percent). However, the revised FY 2001 target amount for a long-term 
care hospital cannot exceed its wage-adjusted national cap as required 
by section 1886(b)(3) of the Act, as amended by section 307(a) of 
Public Law 106-554.
    For cost reporting periods beginning in FY 2002, in the May 4, 2001 
proposed rule, we included the following proposed caps:

------------------------------------------------------------------------
                                                   Labor-     Nonlabor-
      Class of excluded hospital or unit          related      related
                                                   share        share
------------------------------------------------------------------------
Psychiatric...................................       $8,404      $ 3,341
Rehabilitation................................      $15,689       $6,237
Long-Term Care................................      $31,399      $12,483
------------------------------------------------------------------------

    In this final rule, using updated data, we have recalculated the 
proposed caps for cost reporting periods beginning in FY 2002. The 
final FY 2002 caps are listed below:

------------------------------------------------------------------------
                                                   Labor-     Nonlabor-
      Class of excluded hospital or unit          related      related
                                                    shae        share
------------------------------------------------------------------------
Psychiatric...................................       $8,429       $3,351
Rehabilitation................................      $15,736       $6,256
Long-Term Care................................      $31,490      $12,519
------------------------------------------------------------------------

    Regulations at Sec. 413.40(d) specify the formulas for determining 
bonus and relief payments for excluded hospitals and specify 
established criteria for an additional bonus payment for continuous 
improvement. Regulations at Sec. 413.40(f)(2)(ii) specify the payment 
methodology for new hospitals and hospital units (psychiatric, 
rehabilitation, and long-term care) effective October 1, 1997.

[[Page 39954]]

V. Tables

    This section contains the tables referred to throughout the 
preamble to this final rule and in this Addendum. For purposes of this 
final rule, and to avoid confusion, we have retained the designations 
of Tables 1 and 5 that were first used in the September 1, 1983 initial 
prospective payment final rule (48 FR 39844). Tables 1A, 1C, 1D, 2, 3A, 
3B, 4A, 4B, 4C, 4F, 4G, 4H, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 
8A, and 8B are presented below. The tables presented below are as 
follows:

Table 1A--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, 
Labor/Nonlabor
Table 1D--Capital Standard Federal Payment Rate
Table 2--Hospital Average Hourly Wage for Federal Fiscal Years 2000 
(1996 Wage Data), 2001 (1997 Wage Data) and 2002 (1998 Wage Data) Wage 
Indexes and 3-Year Average of Hospital Average Hourly Wages
Table 3A--FY 2002 and 3-Year Average Hourly Wage for Urban Areas
Table 3B--FY 2002 and 3-Year Average Hourly Wage for Rural Areas
Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for 
Urban Areas
Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for 
Rural Areas
Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for 
Hospitals That Are Reclassified
Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment 
Factor (GAF)
Table 4G--Pre-Reclassified Wage Index for Urban Areas
Table 4H--Pre-Reclassified Wage Index for Rural Areas
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting 
Factors, Geometric and Arithmetic Mean Length of Stay
Table 6A--New Diagnosis Codes
Table 6B--New Procedure Codes
Table 6C--Invalid Diagnosis Codes
Table 6D--Invalid Procedure Codes
Table 6E--Revised Diagnosis Code Titles
Table 6F--Revised Procedure Code Titles
Table 6G--Additions to the CC Exclusions List
Table 6H--Deletions to the CC Exclusions List
Table 7A--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 2000 MedPAR Update 3/01 GROUPER V18.0
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 2000 MedPAR Update 3/01 GROUPER V19.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban 
and Rural Hospitals (Case Weighted) July 2001
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case 
Weighted) July 2001

   Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
                                Nonlabor
------------------------------------------------------------------------
          Large Urban Areas                       Other Areas
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
      $2,955.44          $1,201.30          $2,908.65         $1,182.27
------------------------------------------------------------------------


               Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                         Large Urban Areas                  Other Areas
                                                 ---------------------------------------------------------------
                                                       Labor         Nonlabor          Labor         Nonlabor
----------------------------------------------------------------------------------------------------------------
National PR.....................................       $2,929.57       $1,190.78       $2,929.57       $1,190.78
Puerto Rico.....................................        1,420.07          571.61        1,397.59          562.56
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                               Rate
------------------------------------------------------------------------
National................................................         $390.74
Puerto Rico.............................................          187.73
------------------------------------------------------------------------

    --------------------
* Asterisk denotes wage data not available for the provider that year.

** The 3-year average hourly wage is weighted by salaries and hours.

[[Page 39954]]



Table 2.--Hospital Average Hourly Wage for Federal Fiscal Years 2000 (1996 Wage Data), 2001 (1997 Wage Data) and
             2002 (1998 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages
----------------------------------------------------------------------------------------------------------------
                                                                                                      Average**
                                                                Average      Average      Average       Hourly
                        Provider No.                             Hourly       Hourly       Hourly      Wage  (3
                                                              Wage  FY 00  Wage  FY 01  Wage  FY 02      yrs)
----------------------------------------------------------------------------------------------------------------
010001......................................................      15.8484      16.4088      17.4467      16.5711
010004......................................................      15.0194      17.9732      19.0010      17.1863
010005......................................................      16.2615      17.5985      18.6554      17.4986
010006......................................................      17.3081      16.7480      17.6115      17.2150
010007......................................................      14.8048      15.4798      15.6788      15.3288

[[Page 39955]]

 
010008......................................................      17.6549      14.7443      17.4728      16.6080
010009......................................................      17.5328      18.7731      18.4979      18.2633
010010......................................................      15.9090      16.4468      16.4664      16.2848
010011......................................................      20.6261      20.7972      22.4292      21.2601
010012......................................................      19.2992      17.7171      15.8686      17.5430
010015......................................................      18.3461      15.4510      19.1178      17.5372
010016......................................................      16.1311      17.2473      20.2198      17.8844
010018......................................................      18.9617      17.6449      18.9388      18.5180
010019......................................................      15.4910      16.3493      17.0856      16.3311
010021......................................................      14.6297      16.2919      15.1241      15.3000
010022......................................................      20.5050      18.5879      17.6435      18.8422
010023......................................................      16.2581      16.1025      16.3209      16.2283
010024......................................................      16.0263      16.2900      15.9034      16.0692
010025......................................................      14.5311      15.1356      15.1548      14.9441
010027......................................................      14.9278      11.7900      16.8595      14.1053
010029......................................................      16.4103      17.6461      18.3605      17.4403
010031......................................................      18.0194      18.7835      18.6402      18.4877
010032......................................................      12.6540      12.5995      15.3590      13.6017
010033......................................................      19.6797      20.3923      21.2986      20.4581
010034......................................................      14.7342      15.0959      15.3639      15.0606
010035......................................................      17.4788      20.1853      15.9439      17.6916
010036......................................................      17.2880      17.8140      17.7166      17.6061
010038......................................................      18.3309      18.2671      19.6098      18.7632
010039......................................................      18.8080      20.1045      20.3406      19.7778
010040......................................................      19.1030      18.9376      20.0983      19.3415
010043......................................................      16.2022      30.7489      18.6640      19.9982
010044......................................................      17.0229      22.0091      24.0265      20.8906
010045......................................................      15.0065      15.2200      17.0417      15.7248
010046......................................................      17.1822      17.3970      18.9737      17.8750
010047......................................................      16.3803      13.3521      15.4190      15.2030
010049......................................................      14.4823      14.7590      15.5246      14.9487
010050......................................................      15.4159      18.5163      17.9830      17.2796
010051......................................................       9.9390      11.9275      11.8108      11.1940
010052......................................................      13.8649      16.5486      18.0653      16.1248
010053......................................................      13.1778      14.6267      15.5649      14.5406
010054......................................................      17.1246      18.5103      19.4955      18.4846
010055......................................................      18.1930      18.9526      18.8590      18.6711
010056......................................................      19.0783      19.2175      19.6577      19.3204
010058......................................................      12.7809      16.1702      16.9715      15.1274
010059......................................................      18.1886      19.1286      18.8020      18.7124
010061......................................................      15.9215      14.9547      14.5003      15.1112
010062......................................................      13.5690      14.7732      12.3259      13.5151
010064......................................................      20.8966      20.4139      19.5256      20.2712
010065......................................................      15.6357      16.4049      16.8752      16.3279
010066......................................................      12.0681      15.4317      13.1559      13.4757
010068......................................................      18.7367      12.0525      18.6925      15.8875
010069......................................................      13.5684      13.8636      14.7211      14.0429
010072......................................................      14.3481      14.9526      16.2339      15.1957
010073......................................................      12.8328      13.8601      14.1273      13.6015
010078......................................................      17.7110      17.9202      18.1363      17.9248
010079......................................................      16.8701      16.4421      17.0648      16.7882
010080......................................................      13.8473            *            *      13.8473
010081......................................................      16.9823      18.9474      17.2996      17.7081
010083......................................................      16.2146      16.8933      18.0312      17.0916
010084......................................................      18.7794      18.4965      18.7769      18.6812
010085......................................................      18.8696      18.4744      19.9023      19.0736
010086......................................................      14.9255      16.6694      16.5711      16.0968
010087......................................................      18.3889      19.0033      18.0567      18.5192
010089......................................................      16.6090      16.8042      17.7800      17.0521
010090......................................................      18.1121      18.3866      18.9445      18.4882
010091......................................................      16.3620      13.9405      17.0799      15.6820
010092......................................................      16.4980      16.9900      17.8144      17.1322
010094......................................................      18.5603            *            *      18.5603

[[Page 39956]]

 
010095......................................................      11.8993      12.4525      12.2597      12.2090
010097......................................................      12.8955      13.0413      12.7286      12.8889
010098......................................................      14.2787      15.9165      14.0300      14.6833
010099......................................................      15.9309      15.9874      15.5619      15.8073
010100......................................................      15.4826      17.2011      17.9430      16.9229
010101......................................................      15.4173      15.3859      14.4625      15.0781
010102......................................................      12.7251      13.7933      13.8136      13.4259
010103......................................................      19.3115      17.9358      17.7242      18.3325
010104......................................................      18.0997      17.7126      16.8457      17.5501
010108......................................................      20.7914      17.9017      19.4617      19.3047
010109......................................................      14.0870      15.3107      14.6752      14.6907
010110......................................................      15.9066      15.6317      15.8283      15.7917
010112......................................................      15.1056      15.1401      16.8271      15.6716
010113......................................................      17.2440      16.9683      16.8936      17.0309
010114......................................................      17.2612      15.2454      17.0760      16.4722
010115......................................................      13.7524      14.6268      14.2261      14.2120
010118......................................................      16.6889      18.8477      17.0834      17.5145
010119......................................................      18.1707      18.8024      19.3942      18.9605
010120......................................................      17.0332      17.2336      18.2567      17.5146
010121......................................................      15.1806      14.6444      14.5262      14.8160
010123......................................................      18.1604      16.7344      19.2140      17.9949
010124......................................................      16.2666      16.2846      16.7465      16.4273
010125......................................................      14.4153      15.5304      16.0136      15.3557
010126......................................................      17.6405      19.5710      19.1065      18.7347
010127......................................................      19.6095      19.5190      18.2786      19.1726
010128......................................................      12.5747      14.5056      14.4322      13.6385
010129......................................................      14.4267      14.7286      16.1733      15.1385
010130......................................................      16.3465      16.6809      19.5573      17.3907
010131......................................................      17.9076      17.8260      20.1883      18.6602
010134......................................................      10.7817      18.8835      19.9856      15.8677
010137......................................................      15.9348      12.1217      20.5828      15.9236
010138......................................................      12.1295      12.8675      14.5254      13.1763
010139......................................................      19.9487      19.0001      20.4331      19.7578
010143......................................................      15.7144      16.7911      17.6212      16.7651
010144......................................................      17.1211      17.1320      18.2040      17.4771
010145......................................................      20.7460      20.8434      20.5895      20.7209
010146......................................................      18.8561      18.5198      19.1415      18.8309
010148......................................................      14.6443      12.2214      15.8349      13.9784
010149......................................................      17.0836      18.6333      18.0156      17.9216
010150......................................................      16.9749      17.8951      18.9359      17.9332
010152......................................................      17.3835      17.8306      18.7677      18.0088
010155......................................................      16.7028       9.0300      15.0689      12.5183
010158......................................................            *      17.3227      18.3957      17.8637
020001......................................................      27.9690      28.1747      28.0394      28.0627
020002......................................................      26.9145      24.5815      25.1987      25.5092
020004......................................................      26.3979      30.5667      25.4679      27.5927
020005......................................................      29.0068      30.2920      29.2378      29.5337
020006......................................................      26.7706      31.2404      28.1417      28.8630
020007......................................................      24.9555      27.8319      32.3852      28.0097
020008......................................................      30.4712      29.4146      30.8691      30.2487
020009......................................................      23.1801      20.1930      18.4660      20.3801
020010......................................................      18.6417      23.6727      22.7559      21.4818
020011......................................................      29.4697      30.4727      28.0658      29.3006
020012......................................................      23.9259      24.8543      25.5320      24.7635
020013......................................................      26.8172      23.8847      28.1557      26.0576
020014......................................................      24.0932      27.3823      24.5875      25.3179
020017......................................................      24.9714      26.8319      28.0572      26.6405
020024......................................................      22.7263      24.0872      25.3205      24.0621
020025......................................................      27.1529      21.7557      20.2583      22.6334
030001......................................................      19.8695      20.3673      21.7869      20.6506
030002......................................................      21.6263      21.5977      21.8375      21.6886
030003......................................................      23.6722      23.4833      22.6804      23.3063
030004......................................................      17.7333      14.0711      15.5478      15.4308

[[Page 39957]]

 
030006......................................................      17.6409      18.2668      20.0273      18.6274
030007......................................................      18.5602      19.6708      21.5169      19.9379
030008......................................................            *      22.2758      22.2190      22.2524
030009......................................................      17.9343      18.1794      18.7557      18.2786
030010......................................................      18.7997      19.0907      19.5123      19.1422
030011......................................................      20.0784      19.2973      19.4310      19.5785
030012......................................................      19.4245      18.9918      20.6585      19.6997
030013......................................................      21.0182      20.7458      20.0535      20.5870
030014......................................................      19.4697      19.9315      19.7966      19.7342
030016......................................................      20.5606      19.3967      19.4785      19.8559
030017......................................................      20.4185      22.8765      21.7938      21.6805
030018......................................................      18.9115      20.2032      20.8980      20.0193
030019......................................................      19.9211      21.7005      21.2540      20.9846
030022......................................................      15.7886      19.2966      19.5794      17.6713
030023......................................................      22.4365      23.6697      24.1678      23.4686
030024......................................................      21.6692      22.2541      23.6009      22.5290
030025......................................................      17.6759      12.7254      11.9894      13.7385
030027......................................................      17.5796      15.7554      17.6555      16.9563
030030......................................................      21.6249      20.8303      21.6932      21.3795
030033......................................................      16.8396      20.0044      20.2820      18.9069
030034......................................................      19.0868      16.8241      20.8689      18.8279
030035......................................................      19.7153      19.2781      20.0226      19.6580
030036......................................................      18.9449      20.7567      21.6371      20.4743
030037......................................................      21.4376      22.8266      23.7615      22.6712
030038......................................................      22.0777      22.6776      22.9822      22.5885
030040......................................................      17.9722      18.5456      19.7636      18.7537
030041......................................................      17.4389      15.8921      18.8717      17.2718
030043......................................................      20.7721      20.9341      20.5598      20.7468
030044......................................................      16.4654      16.8649      17.6575      17.0214
030047......................................................      19.6916      22.6401      21.4412      21.2271
030049......................................................      19.0896      19.0881      19.3580      19.1639
030054......................................................      14.4861      15.3338      15.0657      14.9801
030055......................................................      18.2751      16.3613      20.2991      18.2684
030059......................................................      21.7100      24.0465      22.6279      22.7570
030060......................................................      16.7661      19.2461      18.6313      18.2043
030061......................................................      17.3470      18.9063      19.9047      18.7238
030062......................................................      17.4825      17.6738      18.7172      17.9978
030064......................................................      18.5391      19.5673      20.3837      19.5213
030065......................................................      19.9277      20.5130      20.7838      20.4254
030067......................................................      15.6207      14.4446      17.2778      15.7364
030068......................................................      17.3482      17.3614      17.7208      17.4823
030069......................................................      19.0013      19.0961      21.0936      19.7255
030080......................................................      19.9865      20.5144      20.6581      20.3684
030083......................................................      23.6433      23.3355      23.5229      23.4991
030085......................................................      17.8402      21.0954      20.8690      19.9451
030086......................................................      18.5030      19.5436            *      19.0352
030087......................................................      20.0469      21.4084      21.9465      21.1838
030088......................................................      19.5772      19.8682      20.5340      20.0152
030089......................................................      19.9018      20.4019      20.9516      20.4404
030092......................................................      21.5628      20.6986      21.8308      21.3646
030093......................................................      19.4688      19.7262      20.4314      19.9052
030094......................................................      19.4773      21.6218      22.8123      21.4086
030095......................................................      14.2499      13.7293      13.7664      13.9087
030099......................................................      18.0747      16.1541      18.2263      17.4781
030100......................................................            *            *      23.7609      23.7609
030101......................................................            *            *      19.2547      19.2547
030102......................................................            *            *      18.2413      18.2413
040001......................................................      15.5735      15.1624      16.9178      15.8741
040002......................................................      14.0865      13.0592      15.1107      14.0333
040003......................................................      14.0027      14.2089      15.5740      14.5731
040004......................................................      17.2926      17.8476      17.9034      17.6718
040005......................................................      12.8825      13.2597      11.1318      12.3937
040007......................................................      19.5299      21.9583      18.6998      19.9568

[[Page 39958]]

 
040008......................................................      12.6974      15.3040      14.7985      14.3087
040010......................................................      17.6231      18.6023      19.4913      18.6031
040011......................................................      12.2654      14.5319      16.0995      14.1756
040014......................................................      15.3853      17.6340      18.1434      17.0051
040015......................................................      14.6045      16.5891      15.5207      15.5649
040016......................................................      17.5431      19.0295      20.2321      18.9152
040017......................................................      14.9533      13.5098      15.4736      14.6592
040018......................................................      17.5602      17.6027      18.7463      17.9749
040019......................................................      25.7080      22.6769      23.4163      23.8479
040020......................................................      14.8059      16.4827      18.9844      16.6335
040021......................................................      16.4628      17.6398      19.6835      17.8176
040022......................................................      16.0006      17.0397      20.8281      17.7640
040024......................................................      15.7282      14.4541      17.6607      15.9615
040025......................................................      10.9496      11.5079      13.4705      11.8847
040026......................................................      18.2398      19.5563      19.7924      19.1863
040027......................................................      14.5406      16.0975      17.4431      16.0716
040028......................................................      12.8409      14.6584      13.9946      13.7921
040029......................................................      17.7777      17.8787      21.1370      18.9480
040030......................................................      14.1541      13.5428      11.2402      12.7784
040032......................................................      13.3280      13.7030      13.2872      13.4471
040035......................................................      11.2123      12.8300      10.9569      11.6408
040036......................................................      17.9080      18.9757      20.2012      19.0415
040037......................................................      13.4815      14.6559      14.0941      14.0704
040039......................................................      13.8386      14.3576      14.7177      14.3115
040040......................................................      17.4283      18.0895      19.1984      18.2668
040041......................................................      13.3613      15.9896      16.4624      15.2103
040042......................................................      14.6641      15.2142      15.2057      15.0333
040044......................................................      11.4422      12.6275      13.3501      12.5381
040045......................................................      18.7724      14.9429      16.2469      16.4870
040047......................................................      16.3948      16.8654      17.5336      16.9538
040048......................................................      15.8203            *            *      15.8203
040050......................................................      11.7934      13.3818      14.0036      13.0341
040051......................................................      16.2803      15.8627      16.6039      16.2390
040053......................................................      15.8193      16.3610      15.0219      15.7502
040054......................................................      15.0412      15.3219      14.2577      14.8844
040055......................................................      16.1029      17.1269      18.0414      17.0866
040058......................................................      15.6706      17.6766      16.4278      16.6344
040060......................................................      11.4686      12.8148      17.9805      13.6105
040062......................................................      17.2757      18.2048      17.8902      17.8204
040064......................................................      12.4007      10.7255      11.5029      11.4801
040066......................................................      17.6429      18.3377      19.7144      18.5416
040067......................................................      13.4930      14.6014      14.4741      14.1956
040069......................................................      16.1147      17.5052      17.0026      16.8681
040070......................................................      15.4757      16.9027      16.9700      16.4358
040071......................................................      16.3022      16.9610      17.6144      16.9553
040072......................................................      15.8425      16.0895      17.4960      16.4940
040074......................................................      17.3819      18.3224      18.7542      18.1968
040075......................................................      12.7496      13.3623      14.0975      13.3977
040076......................................................      18.5512      19.0732      20.5840      19.3801
040077......................................................      12.4625      12.9211      13.9114      13.0965
040078......................................................      17.8573      18.7600      18.5821      18.4100
040080......................................................      15.7397      19.2461      19.3707      18.0636
040081......................................................      10.6791      11.3169      11.1332      11.0311
040082......................................................      16.5127      16.2152      15.1331      15.9302
040084......................................................      17.2469      17.2613      17.7295      17.4070
040085......................................................      15.7765      16.8957      16.5216      16.3838
040088......................................................      15.6710      17.9636      17.1624      16.9372
040090......................................................      17.5503      17.8282      19.0824      18.0989
040091......................................................      17.0444      19.8700      20.1378      18.8893
040093......................................................      12.9010      12.3537      13.9741      13.0114
040100......................................................      14.9688      14.7587      15.6833      15.1704
040105......................................................      14.2409      15.3319      14.3896      14.6616
040106......................................................      15.4000      15.6545      18.1341      16.4515

[[Page 39959]]

 
040107......................................................      19.6184      18.8120      17.8628      18.6841
040109......................................................      13.9807      14.6266      16.6278      15.0815
040114......................................................      18.3133      18.8743      21.1231      19.3828
040116......................................................      19.5695      20.2716            *      19.9151
040118......................................................      17.4300      19.3720      18.2123      18.3407
040119......................................................      15.3847      15.5338      16.9407      15.9572
040124......................................................      17.2547      19.1349      19.2889      18.5723
040126......................................................      11.6845      12.5368      11.6517      11.9404
040132......................................................      13.1760      17.5179      10.3875      13.4483
040134......................................................            *      18.0787      19.0185      18.5701
040135......................................................            *      22.6761      23.0084      22.8797
050002......................................................      27.6006      37.8295      36.9630      33.5586
050006......................................................      19.5272      19.5594      18.2061      19.0382
050007......................................................      29.5398      30.7126      30.8676      30.4910
050008......................................................      25.8570      26.2458      26.3682      26.1654
050009......................................................      26.2506      26.8159      28.4734      27.2303
050013......................................................      24.8541      23.2201      28.0569      25.1985
050014......................................................      24.5302      22.8478      23.6745      23.6450
050015......................................................      25.3838      26.2481      27.7731      26.4938
050016......................................................      20.1542      20.5566      21.2045      20.6377
050017......................................................      23.6639      23.9625      25.6178      24.4113
050018......................................................      14.6622      15.4721      15.2903      15.1444
050021......................................................      28.5003      25.8966            *      27.2682
050022......................................................      22.9583      24.0318      24.5254      23.8802
050024......................................................      20.3427      21.3989      22.4274      21.4070
050025......................................................      21.9952      23.3896      24.8245      23.3764
050026......................................................      28.6850      27.8736      23.1904      26.4206
050028......................................................      16.4531      16.4671      17.6138      16.8496
050029......................................................      23.2911      25.1259      24.6839      24.3441
050030......................................................      21.0096      20.9812      21.5621      21.1955
050032......................................................      22.5868      25.2010      24.3598      24.0616
050033......................................................      24.5609      24.9328      32.0179      27.2378
050036......................................................      20.4703      21.2420      21.8239      21.1856
050038......................................................      27.8274      28.6528      29.9698      28.8293
050039......................................................      22.2524      22.7117      22.8288      22.6033
050040......................................................      30.6664      32.1287      30.2607      31.0150
050042......................................................      22.2343      24.8067      24.5260      23.8317
050043......................................................      33.2286      32.9958      33.8255      33.3456
050045......................................................      20.7307      19.8831      21.1474      20.5973
050046......................................................      31.3831      25.3185      25.2005      27.4555
050047......................................................      29.4412      29.9255      29.9580      29.7840
050051......................................................      17.8401      17.8945      18.7809      18.1179
050054......................................................      19.3686      20.7212      22.0982      20.7075
050055......................................................      29.0872      29.3984      29.2730      29.2593
050056......................................................      23.8507      27.4321      23.8396      24.9757
050057......................................................      21.7581      21.1554      20.7420      21.1969
050058......................................................      25.7261      23.1641      23.3009      23.9601
050060......................................................      20.9219      20.7747      20.5450      20.7207
050061......................................................      23.7443      23.5454      24.5488      23.9503
050063......................................................      23.0724      24.8851      25.7593      24.5061
050065......................................................      21.1848      24.0420      24.6290      23.1479
050066......................................................      21.4187      16.5725      16.1649      17.6784
050067......................................................      21.3029      23.1966      25.8857      23.3989
050068......................................................      28.4804      20.6851      19.3615      22.4409
050069......................................................      29.2980      25.9420      24.6153      26.4351
050070......................................................      32.5964      32.5166      34.0721      33.0817
050071......................................................      33.1379      33.1850      34.4367      33.6139
050072......................................................      32.9660      33.2858      39.7321      35.2928
050073......................................................      34.6111      33.3922      32.8555      33.5664
050075......................................................      33.5246      33.9095      33.7160      33.7090
050076......................................................      33.8835      27.7797      33.9752      31.7128
050077......................................................      23.2986      24.1019      24.1404      23.8541
050078......................................................      22.8023      23.0736      24.3150      23.3638

[[Page 39960]]

 
050079......................................................      34.4253      33.2432      30.0167      32.3461
050082......................................................      21.7004      22.1009      23.7617      22.5498
050084......................................................      23.0966      23.5866      25.4517      24.0054
050088......................................................      24.0634      20.8406      24.9641      23.1779
050089......................................................      20.0194      20.9117      22.8450      21.2533
050090......................................................      23.8969      23.4097      24.6070      23.9625
050091......................................................      22.2220      25.2792      23.7713      23.6457
050092......................................................      15.3841      16.7969      17.1211      16.4241
050093......................................................      24.0837      25.2130      25.6647      24.9860
050095......................................................      33.3761      33.6718      30.4847      32.6392
050096......................................................      21.6752      20.0487      22.7394      21.3870
050097......................................................      22.6147      16.7054      22.5991      20.1968
050099......................................................      24.2921      24.8091      25.3722      24.8349
050100......................................................      30.0552      29.8758      25.2031      28.1754
050101......................................................      30.0132      31.0264      31.8957      30.9871
050102......................................................      21.2947      22.2937      24.0014      22.4745
050103......................................................      25.3384      24.7932      25.4133      25.1832
050104......................................................      25.4407      25.5797      26.9726      25.9841
050107......................................................      21.7649      21.2690      22.2019      21.7497
050108......................................................      25.2116      23.5564      25.1758      24.5678
050109......................................................      26.4768            *            *      26.4768
050110......................................................      20.1769      20.1870      19.9589      20.1175
050111......................................................      21.7397      21.5487      20.7897      21.3840
050112......................................................      26.2922      25.3015      26.8182      26.1335
050113......................................................      27.7805      28.8420      28.5224      28.4025
050114......................................................      25.9073      24.7286      26.6757      25.7599
050115......................................................      21.0499      21.3291      23.0182      21.8124
050116......................................................      25.5919      25.2130      24.9196      25.2412
050117......................................................      20.4379      23.3612      22.2123      21.9903
050118......................................................      23.9976      23.7698      23.7129      23.8243
050121......................................................      18.8818      19.5252      18.7272      19.0416
050122......................................................            *      26.3172      26.9546      26.6358
050124......................................................      23.0193      22.7736      24.5069      23.3667
050125......................................................      24.0434      29.6147      32.0230      28.3742
050126......................................................      23.8424      23.9247      24.6752      24.1448
050127......................................................      19.7654      22.1937      20.9027      20.9520
050128......................................................      24.1801      25.7240      26.6132      25.5185
050129......................................................      27.1586      26.5030      24.0108      25.7227
050131......................................................      29.0570      31.0732      32.5462      30.8106
050132......................................................      22.9139      24.0834      24.0173      23.6527
050133......................................................      24.4011      24.9746      23.2093      24.1354
050135......................................................      27.0341      23.2361      24.7157      24.9796
050136......................................................      24.4336      24.7921      24.7280      24.6450
050137......................................................      30.0725      32.6507      32.9192      31.8970
050138......................................................      37.4088      37.3286      38.1584      37.6483
050139......................................................      31.3785      32.9351      31.4984      31.9286
050140......................................................      33.6644      34.1499      32.7609      33.4990
050144......................................................      25.7483      27.8751      27.4069      26.9409
050145......................................................      33.0620      32.3857      34.5185      33.3152
050148......................................................      21.0584      21.9211      20.0971      20.9748
050149......................................................      23.3754      24.6078      26.8674      24.8666
050150......................................................      23.4777      24.9073      24.6596      24.3771
050152......................................................      27.7504      34.0766      33.3305      31.5833
050153......................................................      29.5915      30.5714      32.3389      30.8441
050155......................................................      22.9420      21.0257      25.3354      22.9852
050158......................................................      27.9789      27.5623      28.6071      28.0313
050159......................................................      25.2105      23.2912      22.5313      23.6099
050167......................................................      21.6778      21.9128      21.8796      21.8226
050168......................................................      25.2504      23.3511      25.1937      24.5830
050169......................................................      24.6361      22.3888      24.8407      23.8796
050170......................................................      22.1989      23.9574      24.3654      23.4164
050172......................................................      17.6976      20.1841      19.6120      19.1630
050173......................................................      23.3255      24.5545      24.8694      24.1923

[[Page 39961]]

 
050174......................................................      31.2136      30.2140      30.2775      30.5443
050175......................................................      27.7875      27.2806      24.7548      26.2477
050177......................................................      20.2485      21.7943      21.1396      21.0728
050179......................................................      19.2861      21.7175      23.8868      21.4573
050180......................................................      32.1883      31.8947      33.3257      32.5107
050183......................................................      19.9765      20.3638            *      20.1665
050186......................................................      21.9062      22.4155      23.6288      22.6119
050188......................................................      27.4364      28.0918      28.2364      27.9460
050189......................................................      23.2415      22.8687      27.4071      24.6245
050191......................................................      26.7297      20.8321      25.3516      24.1885
050192......................................................      17.8095      18.6701      14.1996      16.5873
050193......................................................      23.7260      22.6316      24.9444      23.7567
050194......................................................      28.2701      29.7371      29.5678      29.1714
050195......................................................      34.7789      35.5621      36.9068      35.7823
050196......................................................      16.6866      18.5180      18.2411      17.8430
050197......................................................      31.4513      35.7449      32.4030      33.0882
050204......................................................      24.3944      23.6105      22.7099      23.5849
050205......................................................      21.1545      23.6831      24.1691      23.0778
050207......................................................      20.8576      21.6214      22.9941      21.8243
050211......................................................      31.2175      31.6084      31.7280      31.5153
050213......................................................      20.7338      21.4806      21.4951      21.1847
050214......................................................      20.8704      21.7335      24.0276      22.1888
050215......................................................      28.4058      29.8563      35.0459      31.0290
050217......................................................      19.8913      19.6010      20.2042      19.9076
050219......................................................      25.4730      21.7444      21.2458      22.6404
050222......................................................      27.0713      27.4809      23.3563      25.7959
050224......................................................      23.7942      23.5316      23.5101      23.6043
050225......................................................      20.7978      23.3480      21.6820      21.9144
050226......................................................      26.9297      27.7315      24.4443      26.2380
050228......................................................      30.3772      34.0711      34.2596      32.7722
050230......................................................      25.3640      27.7357      26.6291      26.5638
050231......................................................      25.5798      26.1508      26.7321      26.1759
050232......................................................      23.3849      24.3072      24.5245      24.0793
050233......................................................      31.3954            *            *      31.3954
050234......................................................      28.5188      25.7035      24.6126      26.2702
050235......................................................      25.8595      25.2527      27.0922      26.0726
050236......................................................      26.2723      26.9803      25.9458      26.4027
050238......................................................      24.0043      24.2922      24.5823      24.2994
050239......................................................      20.4071      22.6625      23.2711      22.0940
050240......................................................      25.2540      26.3657      26.7620      26.0528
050241......................................................      27.2198      26.3740      29.8345      27.7426
050242......................................................      30.1432      31.1576      32.0829      31.1145
050243......................................................      22.9123      28.9635      26.4627      26.1049
050245......................................................      24.3969      23.8124      23.2716      23.7873
050248......................................................      27.4214      26.2015      27.6457      27.0910
050251......................................................      18.4990      21.6574      23.6360      21.1907
050253......................................................      20.0658      16.0701      16.7540      17.4281
050254......................................................      19.6899      19.3126      20.1176      19.7146
050256......................................................      23.5302      23.6887      23.4835      23.5723
050257......................................................      19.5923      15.2306      17.2596      17.1813
050260......................................................      23.5201      23.2421      27.4234      24.5032
050261......................................................      20.4496      20.0552      20.1040      20.2029
050262......................................................      29.0054      28.8785      29.5550      29.1532
050264......................................................      29.4542      32.1312      36.0331      32.4545
050267......................................................      24.7464      26.2264      26.0401      25.6690
050270......................................................      23.7260      24.0439      25.3757      24.3521
050272......................................................      21.4374      22.4247      23.0587      22.2948
050274......................................................      21.1943      20.0422            *      20.6204
050276......................................................      28.5051      29.8624      33.3302      30.5715
050277......................................................      22.3125      20.0520      26.0822      22.5131
050278......................................................      23.8434      24.7787      23.9289      24.1853
050279......................................................      21.0570      20.8444      21.8949      21.2309
050280......................................................      24.4267      25.2149      25.6651      25.1337

[[Page 39962]]

 
050281......................................................      18.5907      19.6888      24.2251      20.7934
050282......................................................      24.4593      28.8261      25.4428      26.2214
050283......................................................      27.8763      29.7734      31.7669      30.1598
050286......................................................      17.8045      16.5708      19.4241      17.6805
050289......................................................      26.7185      34.1393      30.4750      30.2632
050290......................................................      26.3745      28.6231      29.6796      28.2631
050291......................................................      26.4908      30.2748      29.4029      28.6899
050292......................................................      22.4878      21.6243      20.8410      21.6183
050293......................................................      19.1761      22.2963      24.1875      21.4642
050295......................................................      20.7393      21.2892      21.7883      21.2665
050296......................................................      25.3166      27.2948      28.3906      27.0098
050298......................................................      20.5181      24.4477      23.2006      22.6781
050299......................................................      25.7697      26.4543      25.5035      25.9187
050300......................................................      22.7423      23.5116      25.9228      24.1102
050301......................................................      26.0355      22.5201      21.1403      23.0323
050302......................................................      29.2007            *            *      29.2007
050305......................................................      32.7082      34.5185      36.7908      34.7340
050307......................................................      27.9830      17.2147            *      21.7503
050308......................................................      28.4019      29.3803      28.9284      28.9113
050309......................................................      24.4034      23.7884      25.3515      24.5133
050310......................................................      20.6181            *            *      20.6181
050312......................................................      23.7936      26.7617      26.0015      25.5439
050313......................................................      23.1009      21.7577      25.6827      23.5594
050315......................................................      21.9227      24.7086      22.7359      23.0264
050317......................................................      19.4479      21.6937            *      20.5789
050320......................................................      30.6054      30.4101      32.4809      31.1252
050324......................................................      26.2735      26.6049      25.3694      26.0738
050325......................................................      23.2355      24.4862      23.6327      23.7872
050327......................................................      22.8511      23.9484      25.6450      24.1469
050328......................................................      23.1889            *            *      23.1889
050329......................................................      21.4125      19.7455      21.6984      20.9322
050331......................................................      25.5252      22.2536      25.0230      24.1261
050333......................................................      20.1468      19.4589      19.1449      19.5671
050334......................................................      32.0169      34.2330      34.2557      33.5307
050335......................................................      20.2013      23.0258      22.9926      22.0827
050336......................................................      20.0980      20.7979      21.3402      20.7523
050342......................................................      19.3524      20.1841      20.8255      20.1210
050343......................................................      17.3394      17.2085            *      17.2799
050348......................................................      20.7505      23.8779      25.1085      23.3219
050349......................................................      15.0515      14.9754      15.0667      15.0310
050350......................................................      25.0676      24.8340      26.4161      25.4163
050351......................................................      24.6936      25.4791      24.8121      24.9948
050352......................................................      23.5927      26.1380      26.4262      25.4187
050353......................................................      23.2468      23.0564      23.2699      23.1944
050355......................................................      17.1597      17.2778      21.0969      18.0157
050357......................................................      23.6411      22.6545      24.5345      23.6386
050359......................................................      20.4005      17.7907      21.7548      19.8316
050360......................................................      31.7608      31.3526      31.7583      31.6236
050366......................................................      21.3442      23.7528      19.6823      21.4770
050367......................................................      29.4763      28.2805      30.7328      29.5063
050369......................................................      24.2604      27.0548      26.2234      25.8174
050373......................................................      26.6548      26.9776      27.8275      27.1333
050376......................................................      25.3036      26.5840      28.0990      26.5882
050377......................................................      25.6401      17.1764      17.0012      20.1035
050378......................................................      22.2363      25.9810      26.9101      24.8709
050379......................................................      15.4994      15.2022      18.4278      16.2767
050380......................................................      30.5790      31.4343      31.9578      31.3600
050382......................................................      26.1465      26.1398      25.9244      26.0725
050385......................................................      25.9188      24.6083            *      25.2398
050388......................................................      13.7863      19.1512      22.0122      17.5709
050390......................................................      22.5668      25.0426      24.2700      23.9349
050391......................................................      22.4881      18.9266      20.0615      20.3952
050392......................................................      21.9324      21.6729      22.9430      22.1487

[[Page 39963]]

 
050393......................................................      23.1387      25.6964      24.1981      24.3082
050394......................................................      22.2424      23.0604      23.1526      22.8333
050396......................................................      23.6322      24.0636      25.3729      24.3512
050397......................................................      20.7698      20.2601      20.6397      20.5453
050401......................................................      17.7807      20.7473      18.4593      18.9557
050404......................................................      19.2754      17.3396      15.9839      17.4356
050406......................................................      16.8931      17.3016      17.8596      17.3407
050407......................................................      30.1222      29.9642      30.8346      30.2996
050410......................................................      16.4735      17.6769      19.8508      17.8663
050411......................................................      32.2364      34.8899      33.1943      33.4145
050414......................................................      24.4243      24.2060      25.9723      24.9224
050417......................................................      21.8884      21.5739      23.3005      22.2456
050419......................................................      23.1162      23.7584      23.4936      23.4646
050420......................................................      22.6819      22.3166      23.5438      22.8448
050423......................................................      23.3296      17.3771      21.3552      20.6272
050424......................................................      23.7788      22.8350      24.0727      23.5641
050425......................................................      33.6911      32.8364      35.3712      34.0224
050426......................................................      23.7082      25.2453      29.0120      25.8759
050427......................................................      20.0698      20.1674      16.4330      18.6499
050430......................................................      21.3428      23.8788      21.2275      22.2136
050432......................................................      21.4984      24.4133      24.5630      23.4427
050433......................................................      16.8035      17.4643      18.9021      17.7004
050434......................................................      15.6348      19.7591            *      17.6624
050435......................................................      32.9865      25.6676      23.3426      26.8858
050436......................................................      16.3594      14.8121            *      15.5729
050438......................................................      24.0828      25.0138      23.2583      24.1266
050440......................................................      21.1100      23.5167      22.5400      22.3553
050441......................................................      28.7067      28.9804      31.8774      29.8169
050443......................................................      16.4308      19.9020      17.2875      17.7906
050444......................................................      24.6741      21.4533      22.4530      22.8550
050446......................................................      20.5383      20.4908      22.3422      21.1378
050447......................................................      18.4183      17.9751      18.9851      18.4558
050448......................................................      20.0757      19.7046      21.7718      20.5035
050449......................................................      22.1784      23.8001      23.4614      23.1469
050454......................................................      28.6857      28.7432      30.0792      29.2410
050455......................................................      19.9209      20.1643      19.8577      19.9840
050456......................................................      17.6229      20.1254      18.1585      18.5890
050457......................................................      31.2489      34.4949      32.1910      32.6376
050459......................................................      37.0914            *            *      37.0914
050464......................................................      22.3142      25.3292      25.7710      24.4665
050468......................................................      23.1701      23.3050      22.2926      22.8998
050469......................................................      23.4404      23.8759      24.5205      23.8915
050470......................................................      17.0353      16.0292      16.0805      16.3264
050471......................................................      24.2887      25.6172      27.1597      25.6415
050476......................................................      23.1428      22.4754      24.0253      23.2552
050477......................................................      27.7855      27.9595      27.5819      27.7866
050478......................................................      23.0530      24.5401      26.3306      24.6133
050481......................................................      26.8293      28.9722      27.7973      27.8692
050482......................................................      16.9268      18.1217      16.0114      17.0134
050483......................................................      21.6038      22.7182            *      22.1632
050485......................................................      23.1933      24.1983      24.6906      24.0174
050486......................................................      24.4967            *            *      24.4967
050488......................................................      32.8620      34.6939      31.7481      33.0979
050491......................................................      25.1011      26.8703      27.4600      26.4606
050492......................................................      21.4156      19.5457      20.5030      20.4277
050494......................................................      25.4078      29.2621      29.1296      27.9125
050496......................................................      33.0168      32.5168      34.9704      33.4862
050497......................................................            *      13.8110      15.4115      14.5264
050498......................................................      24.8445      24.9677      26.1716      25.3085
050502......................................................      22.6253      22.3788      25.3701      23.4214
050503......................................................      23.5911      24.4069      23.3745      23.7879
050506......................................................      21.2165      25.0845      25.0333      23.8164
050510......................................................      33.4617      33.3774      33.7481      33.5309

[[Page 39964]]

 
050512......................................................      34.3138      35.3581      34.4368      34.6837
050515......................................................      35.0412      35.3419      33.7321      34.6571
050516......................................................      25.1850      24.7992      26.1969      25.4171
050517......................................................      20.3733      20.9550      22.0985      21.1081
050522......................................................      31.7326      35.3784      36.2127      34.2256
050523......................................................      28.4235      27.0544      31.2522      28.8864
050526......................................................      26.9206      23.8099      26.4014      25.6096
050528......................................................      18.6898      19.0611      18.9155      18.8867
050531......................................................      20.7332      22.7308      21.3948      21.6689
050534......................................................      23.3026      24.0700      24.0001      23.7954
050535......................................................      24.2257      25.4215      26.8511      25.4120
050537......................................................      22.2073      22.2256      24.0354      22.8159
050539......................................................      23.2501      20.7129      23.3846      22.4405
050541......................................................      34.6195      34.4573      36.6149      35.2691
050542......................................................      17.8537      16.0892      17.7737      17.2018
050543......................................................      23.0437      22.3994      21.6795      22.3610
050545......................................................      27.5713      26.3304      31.7280      27.9472
050546......................................................      27.7557      26.1949      38.8087      28.7303
050547......................................................      27.0845      26.8305      37.7681      28.7499
050548......................................................      26.5922      28.8083      29.8516      28.2370
050549......................................................      27.9098      27.2765      28.9615      28.0769
050550......................................................      25.7546      24.8048      25.6588      25.4034
050551......................................................      24.0488      25.4652      24.8084      24.7966
050552......................................................      22.8731      21.5216      20.3239      21.6775
050557......................................................      22.1385      21.1243      22.2562      21.8314
050559......................................................      24.6689      23.5759      24.7866      24.3485
050561......................................................      33.9268      34.5791      33.4423      33.9701
050564......................................................      24.5099      23.5922      24.2091      24.0891
050565......................................................      22.8785      23.7829      20.8349      22.3644
050566......................................................      18.3297      17.4423      22.3448      19.2949
050567......................................................      24.2349      24.6454      25.0787      24.6746
050568......................................................      20.5205      19.5816      20.5376      20.2025
050569......................................................      24.9453      26.5479      27.3429      26.2484
050570......................................................      24.4961      25.2294      25.8619      25.1838
050571......................................................      24.3741      26.2039      24.0154      24.8290
050573......................................................      25.1398      24.9644      25.6589      25.2612
050575......................................................            *      19.5611      20.7090      20.0979
050577......................................................      20.5177      25.1549      23.5487      22.9797
050578......................................................      28.9073      28.5379      28.9009      28.7846
050579......................................................      30.0694      30.4952      29.9348      30.1803
050580......................................................      23.9183      25.9004      24.6962      24.8350
050581......................................................      23.5660      23.8584      24.9807      24.1454
050583......................................................      23.3609      24.3987      25.8800      24.5448
050584......................................................      23.1610      21.2366      19.5805      21.2667
050585......................................................      26.4985      25.9426      24.2824      25.5872
050586......................................................      23.8402      23.4079      23.1850      23.4570
050588......................................................      30.3873      25.3094      24.5472      26.4705
050589......................................................      24.3453      24.8698      23.8880      24.3389
050590......................................................            *      22.4480      24.4797      23.4541
050591......................................................      22.3224      23.9412      25.0209      23.7207
050592......................................................      26.0528      21.1745      22.1174      23.0414
050594......................................................      22.7826      27.1584      27.7002      25.6455
050597......................................................      23.1789      22.8523      23.3280      23.1176
050598......................................................      28.1062      24.3597      23.9202      25.2869
050599......................................................      26.3191      29.1221      26.0892      27.1846
050601......................................................      32.8704      31.8670      29.7417      31.4201
050603......................................................      22.7500      23.3390      21.7031      22.5608
050604......................................................      33.3239      34.0461      35.4034      34.3023
050607......................................................      24.1052            *            *      24.1052
050608......................................................      16.1529      18.0947      18.1664      17.4208
050609......................................................      31.9340      34.9935      33.5028      33.4973
050613......................................................      23.4779      23.3835      30.2413      25.4419
050615......................................................      23.7015      23.8815      27.5682      24.9089

[[Page 39965]]

 
050616......................................................      22.7960      22.7437      24.9843      23.5101
050618......................................................      21.7032      21.6509      21.4895      21.6219
050623......................................................      30.3208      29.1806      27.5832      29.0384
050624......................................................      22.3419      22.7148      26.4659      23.7251
050625......................................................      24.3503      26.4849      27.5816      26.1377
050630......................................................      24.0961      23.9159      24.2120      24.0782
050633......................................................      21.9790      23.1918      25.4283      23.5401
050635......................................................      37.8481            *            *      37.8481
050636......................................................      20.8349      21.2618      23.5257      21.8335
050638......................................................      23.6341      18.2859      18.2159      19.5807
050641......................................................      21.3605      21.8315      17.1258      19.7042
050644......................................................      23.1229      22.3456      22.1489      22.5048
050661......................................................      20.4769      19.6780            *      20.1699
050662......................................................      28.2910      26.9606      35.0989      28.9225
050663......................................................      23.7097      30.6591      24.9110      25.8492
050667......................................................      24.1064      24.9979      27.5045      25.1663
050668......................................................      39.9001      42.0974      61.7751      44.9671
050670......................................................      21.8750      20.0152      24.6101      21.9523
050674......................................................      36.2361      34.7380      32.4807      34.3308
050675......................................................      15.8423      15.6794            *      15.7602
050676......................................................      17.5302      18.6672      20.2087      18.7455
050677......................................................      33.7056      35.6503      33.6070      34.3198
050678......................................................      22.6591      26.8741      22.7756      23.9129
050680......................................................      27.3188      28.0584      31.4839      28.9200
050682......................................................      17.9715      26.2882      17.3566      19.6443
050684......................................................      21.8067      22.3398      23.3697      22.4849
050685......................................................      32.1330      31.1725      35.1307      32.7762
050686......................................................      33.2515      35.2631      33.4420      33.9679
050688......................................................      29.9990      30.6635      31.0648      30.5922
050689......................................................      34.1851      30.7295      30.9399      31.8127
050690......................................................      33.8277      32.8204      34.8112      33.8469
050693......................................................      33.2977      26.8265      25.5662      28.3155
050694......................................................      22.5719      23.2293      23.5572      23.1120
050695......................................................      23.5215      21.1377      24.4301      23.0784
050696......................................................      26.4103      28.0015      28.3291      27.6235
050697......................................................      21.4716      21.1566      18.2338      20.1433
050699......................................................      28.4754      25.7843      17.5296      23.1610
050700......................................................      28.4522            *            *      28.4522
050701......................................................      27.6190      22.6959      24.3055      24.7548
050702......................................................      12.2518            *            *      12.2518
050704......................................................      20.7568      22.8716      22.7618      22.3025
050707......................................................      27.5065      26.2732      27.8958      27.2979
050708......................................................      21.9149      22.7821      24.8647      23.2324
050709......................................................      19.4255      21.9598      19.4977      20.2535
050710......................................................      26.8095      26.9060      27.5828      27.1479
050713......................................................      15.3027      17.7259      16.8538      16.6077
050714......................................................            *      28.9314      30.1925      29.4900
050715......................................................      19.1151            *            *      19.1151
050717......................................................            *      25.9534      28.7973      27.3346
050718......................................................            *      17.6062      18.0940      17.8064
050719......................................................            *      25.5508      23.0833      23.8495
050720......................................................            *            *      25.8677      25.8677
060001......................................................      20.5908      21.3659      21.1819      21.0411
060003......................................................      19.3243      19.8023      20.4682      19.8685
060004......................................................      21.7899      22.8750      21.4496      22.0469
060006......................................................      17.8613      19.3651      20.0213      19.0568
060007......................................................      16.3833      17.4682      18.2977      17.3945
060008......................................................      17.0944      18.0333      18.4590      17.8646
060009......................................................      21.1795      21.4312      22.7164      21.8027
060010......................................................      22.7241      24.0872      23.6827      23.5135
060011......................................................      21.9727      23.4366      22.3458      22.5831
060012......................................................      19.7746      20.1442      19.4932      19.7974
060013......................................................      19.1369      22.7346      19.1256      20.3432

[[Page 39966]]

 
060014......................................................      20.5353      24.2459      24.3210      23.0067
060015......................................................      23.5675      20.9773      23.2469      22.5866
060016......................................................      15.9627      16.4707      20.2408      17.3661
060018......................................................      21.8607      20.3183      21.5083      21.2146
060020......................................................      17.7250      18.3099      18.8985      18.3187
060022......................................................      19.6488      21.0558      21.0830      20.6200
060023......................................................      19.6534      19.2373      21.5475      20.1296
060024......................................................      22.8347      21.9955      22.9185      22.5887
060027......................................................      21.6731      20.9846      22.0713      21.5836
060028......................................................      22.2461      23.2065      23.1792      22.8860
060029......................................................      21.4111      20.8585      18.2938      20.0752
060030......................................................      20.0345      20.5002      20.3452      20.2923
060031......................................................      19.3998      21.1649      22.5067      20.9951
060032......................................................      22.3702      23.4162      22.8123      22.8765
060033......................................................      13.8165      15.9085      16.0760      15.2591
060034......................................................      21.4110      22.4791      23.2816      22.4305
060036......................................................      19.2386      15.0698      18.5988      17.4095
060037......................................................      14.0458      15.5611      15.4513      15.0213
060038......................................................      14.3084      14.0791      14.3249      14.2429
060041......................................................      14.8299      14.8934      19.1263      15.9980
060042......................................................      20.0815      19.1892      20.8597      19.9134
060043......................................................      13.0544      13.6717      13.4443      13.3963
060044......................................................      22.5286      19.7039      20.8673      21.1240
060046......................................................      20.4359      19.4567      22.2699      20.7384
060047......................................................      15.1181      15.8770      17.1534      15.9786
060049......................................................      20.6427      21.7797      23.0613      21.7878
060050......................................................      16.8012      18.2238      19.0832      18.0606
060052......................................................      12.5517      13.4210      14.8729      13.6675
060053......................................................      14.9399      15.9806      18.0232      16.2596
060054......................................................      19.3943      22.8985      20.4160      20.8278
060056......................................................      17.0509      18.2831      18.1263      17.9597
060057......................................................      23.3804      26.4046      25.4185      25.1123
060058......................................................      16.9064      15.4856      13.8539      15.6088
060060......................................................      14.8894      15.6469      15.6018      15.4330
060062......................................................      14.9354      17.2991      16.8640      16.3901
060063......................................................      15.0896            *            *      15.0896
060064......................................................      20.9349      21.2207      22.7797      21.6636
060065......................................................      24.3032      21.6305      24.5572      23.4210
060066......................................................      14.0672      16.3485      17.2537      15.7129
060068......................................................      19.6355            *            *      19.6355
060070......................................................      16.5821      17.3184      18.8960      17.6173
060071......................................................      16.9545      17.5987      17.4068      17.3254
060073......................................................      15.8385      15.7860      17.0846      16.2338
060075......................................................      22.8498      24.1550      23.8724      23.6295
060076......................................................      19.2861      24.8732      20.3265      21.3796
060085......................................................      13.4761      13.6277      14.3409      13.7955
060087......................................................      21.0277            *            *      21.0277
060088......................................................      16.6753      25.2786      13.7174      17.2655
060090......................................................      14.5096      22.2974      16.3760      17.6196
060096......................................................      23.1232      21.9623      20.8937      21.9261
060100......................................................      21.9983      23.5986      23.9305      23.4279
060103......................................................      22.3414      24.8151      23.5083      23.4950
060104......................................................      22.3008      22.2295      21.1820      21.8472
060107......................................................      13.6449      14.2698      21.9221      15.1674
070001......................................................      26.5150      26.0878      26.3596      26.3266
070002......................................................      25.4570      26.2801      26.1768      25.9680
070003......................................................      26.0894      25.6949      27.5200      26.4175
070004......................................................      23.2664      22.4871      24.2567      23.3158
070005......................................................      25.5739      26.6483      26.9151      26.3676
070006......................................................      28.7139      27.5674      28.6413      28.3103
070007......................................................      27.1867      26.9505      26.3313      26.8152
070008......................................................      26.0269      23.0227      24.2971      24.3585
070009......................................................      23.4686      24.6201      24.1871      24.0886

[[Page 39967]]

 
070010......................................................      25.9375      26.2354      29.2194      27.0543
070011......................................................      23.9603      23.3638      23.0883      23.4486
070012......................................................      25.1022      23.0321      28.8067      25.3536
070015......................................................      25.3317      23.8240      28.1204      25.7263
070016......................................................      26.3005      24.9148      24.4633      25.2035
070017......................................................      24.8038      26.2923      26.0424      25.7039
070018......................................................      28.8776      28.0689      30.6864      29.1923
070019......................................................      24.7025      25.7283      24.9249      25.1145
070020......................................................      23.7227      23.9987      25.9964      24.5532
070021......................................................      26.5173      25.2978      26.3043      26.0246
070022......................................................      25.0845      26.5691      26.9111      26.1557
070024......................................................      25.1491      25.2983      24.8948      25.1081
070025......................................................      25.4055      25.1315      25.4345      25.3241
070026......................................................      18.7892            *            *      18.7892
070027......................................................      23.6381      23.6412      26.8450      24.6648
070028......................................................      24.6913      24.6788      25.7492      25.0300
070029......................................................      22.7507      22.0080      23.9682      22.8885
070030......................................................      24.9676      28.9117      22.1578      25.5338
070031......................................................      21.6565      23.4419      24.1198      23.0342
070033......................................................      28.8099      30.4214      31.4736      30.2068
070034......................................................      29.1220      28.9200      29.4916      29.1706
070035......................................................      23.0574      23.0869      24.1423      23.4347
070036......................................................      28.9463      28.8400      29.9470      29.2263
070039......................................................      21.7791      22.9032      22.3356      22.3067
080001......................................................      25.2849      25.4836      24.8833      25.2209
080002......................................................      15.5984      19.6011      20.1965      18.4286
080003......................................................      22.3957      22.1856      23.1275      22.5300
080004......................................................      19.7725      21.9391      22.9706      21.5842
080005......................................................      14.4289            *            *      14.4289
080006......................................................      22.2632      20.0792      22.6671      21.6173
080007......................................................      20.3833      19.6213      21.3746      20.4985
090001......................................................      25.8921      21.7526      21.5751      23.1400
090002......................................................      19.6997      19.4191      21.5726      20.1912
090003......................................................      28.6092      22.1090      23.1268      24.5792
090004......................................................      24.4267      24.3367      25.5054      24.7042
090005......................................................      24.8766      23.8620      26.3074      24.9846
090006......................................................      20.0816      20.8675      22.0957      21.0167
090007......................................................      21.6551      22.1973      29.2840      24.7855
090008......................................................      21.5972      20.2166      25.2708      22.3042
090010......................................................      15.8676      24.1287      23.6616      20.2595
090011......................................................      27.3741      27.4781      26.6349      27.1495
100001......................................................      17.6948      19.5796      20.2157      19.1458
100002......................................................      21.3243      20.7136      21.0222      21.0141
100004......................................................      15.2465      14.6283      15.4149      15.0845
100006......................................................      20.6302      20.1133      21.2293      20.6802
100007......................................................      21.7217      21.7242      22.1590      21.8790
100008......................................................      20.7232      20.4980      20.8381      20.6876
100009......................................................      24.2947      22.6419      22.1741      22.9648
100010......................................................      21.9101      21.9078      23.0637      22.2904
100012......................................................      18.5169      19.6177      20.4659      19.5030
100014......................................................      19.8352      19.8023      19.5770      19.7276
100015......................................................      18.2394      18.4779      18.0654      18.2696
100017......................................................      17.7739      19.0608      19.8655      18.9086
100018......................................................      20.8392      21.0332      21.6388      21.1816
100019......................................................      19.8134      22.6152      23.5462      21.9719
100020......................................................      26.1783      21.3848      20.7816      22.5004
100022......................................................      25.8853      26.4094      26.5695      26.2778
100023......................................................      21.1068      19.9739      19.1787      20.0604
100024......................................................      20.7760      21.8791      22.1332      21.6047
100025......................................................      19.1219      18.7774      19.4529      19.1169
100026......................................................      20.7591      20.5641      20.9461      20.7639
100027......................................................      12.9410      19.1481      14.7916      15.3484
100028......................................................      19.7491      19.3757      19.3371      19.4791

[[Page 39968]]

 
100029......................................................      19.1768      20.8745      20.8950      20.2753
100030......................................................      18.8229      22.8204      20.5952      20.6758
100032......................................................      19.3165      19.8127      19.7451      19.6185
100034......................................................      18.2314      17.8743      19.5282      18.5138
100035......................................................      19.5842      20.1540      23.8117      21.2289
100038......................................................      24.7851      23.3578      24.5864      24.2183
100039......................................................      20.2529      21.5297      21.7861      21.1854
100040......................................................      18.6417      19.0449      18.6321      18.7662
100043......................................................      17.5215      18.7993      18.8206      18.3605
100044......................................................      21.1370      21.4764      22.7236      21.7975
100045......................................................      20.7688      20.9216      21.0228      20.9056
100046......................................................      21.2094      21.6207      21.3028      21.3728
100047......................................................      18.8677      20.0114      20.6068      19.8263
100048......................................................      13.5021      15.0584      15.7790      14.8232
100049......................................................      18.5598      18.8535      19.1025      18.8421
100050......................................................      16.6058      17.2377      17.9039      17.2452
100051......................................................      18.8377      23.1273      17.9453      19.6449
100052......................................................      16.1855      17.9537      18.1780      17.4312
100053......................................................      18.7103      20.1724      19.6800      19.5213
100054......................................................      18.1853      23.5491      21.1518      20.9367
100055......................................................      17.6226      18.0547      18.8760      18.1971
100056......................................................      23.6545      25.7863      21.8506      23.8349
100057......................................................      18.7489      19.9712      19.5319      19.4242
100060......................................................      22.3904      23.2561      23.5997      23.0802
100061......................................................      21.7923      22.1133      22.9176      22.2483
100062......................................................      17.9575      19.4370      21.4424      19.6570
100063......................................................      16.2324      19.2629      18.4642      17.9066
100067......................................................      17.3950      18.0877      18.4851      17.9682
100068......................................................      18.6480      19.9305      19.8308      19.4718
100069......................................................      16.1393      16.8271      17.3666      16.7757
100070......................................................      20.3358      18.7408      20.0381      19.6563
100071......................................................      16.4756      17.5451      17.7234      17.2640
100072......................................................      19.2223      21.0225      20.5968      20.3580
100073......................................................      18.1554      21.1898      22.2812      20.4948
100075......................................................      18.0548      18.3688      19.4480      18.6211
100076......................................................      16.2469      17.8733      17.8612      17.3644
100077......................................................      19.6214      22.3438      19.0640      20.3179
100078......................................................      18.2791      18.4499      19.2891      18.6609
100080......................................................      21.1603      22.1966      22.7153      22.0462
100081......................................................      13.9564      14.8313      15.4253      14.7661
100082......................................................      19.8033      18.8998            *      19.3432
100084......................................................      20.4002      22.3674      22.7009      21.8810
100085......................................................      21.0802      22.1231            *      21.5986
100086......................................................      21.1625      21.6997      23.3718      22.0734
100087......................................................      23.1162      23.6090      23.6562      23.4609
100088......................................................      20.0571      20.3693      20.5566      20.3435
100090......................................................      17.8768      19.1479      19.7695      18.9939
100092......................................................      18.1953      17.9216      20.1760      18.7907
100093......................................................      16.6310      16.5128      16.8422      16.6633
100098......................................................      19.0319      19.2427      20.8315      19.7124
100099......................................................      15.2983      15.7823      15.7591      15.6112
100102......................................................      19.3330      18.9701      19.7673      19.3542
100103......................................................      18.1019      17.2364      18.7844      18.0201
100105......................................................      21.5028      21.6604      21.8268      21.6611
100106......................................................      19.3113      17.2527      17.4958      17.9164
100107......................................................      18.0142      20.1281      20.0719      19.4041
100108......................................................      11.4692      19.9593      20.1125      16.4375
100109......................................................      22.1715      20.8440      20.8370      21.2360
100110......................................................      19.6439      20.8995      20.1853      20.2509
100112......................................................       9.7706      25.2570      15.2128      15.6728
100113......................................................      22.2584      23.2020      21.3489      22.1642
100114......................................................      23.4501      21.6262      22.8178      22.5825
100117......................................................      18.8619      20.7624      20.6962      20.1889

[[Page 39969]]

 
100118......................................................      19.7608      22.8702      20.7323      21.1427
100121......................................................      19.3435            *      18.5842      18.9363
100122......................................................      18.0551      19.8783      19.2643      19.0686
100124......................................................      19.0527      17.0713      20.4022      18.8192
100125......................................................      17.3358      18.9535      19.6097      18.6719
100126......................................................      18.0943      19.5413      19.3103      18.9490
100127......................................................      19.8727      19.9860      19.2122      19.6859
100128......................................................      21.3653      20.1536      22.8826      21.4045
100129......................................................      18.5723      19.1936            *      18.8646
100130......................................................      19.1052      18.6751      20.0947      19.3019
100131......................................................      22.1680      23.4373      23.1622      22.9338
100132......................................................      16.8978      18.1167      18.7863      17.9218
100134......................................................      13.4711      15.1764      15.9733      14.8260
100135......................................................      17.4785      18.8253      19.1865      18.5050
100137......................................................      19.0464      18.6955      19.5562      19.1372
100138......................................................      11.0135      17.1373      14.9539      13.7935
100139......................................................      15.6444      15.6514      15.2532      15.5227
100140......................................................      17.3518      17.1389      19.0584      17.8826
100142......................................................      18.6812      19.6815      18.4113      18.9199
100144......................................................      15.0197      12.2877            *      13.4059
100145......................................................      19.1143            *            *      19.1143
100146......................................................      17.8692      18.1267      21.3359      19.1001
100147......................................................      14.6751      14.6616      15.2348      14.8665
100150......................................................      21.0224      21.2807      21.5057      21.2659
100151......................................................      19.3990      21.6087      23.8489      21.6478
100154......................................................      19.8485      20.0015      20.4068      20.1020
100156......................................................      17.1335      19.4980      18.4779      18.3856
100157......................................................      21.0324      22.6744      22.6195      22.1032
100159......................................................      16.3778      10.2793      10.7818      11.9429
100160......................................................      21.6339      20.5581      23.3121      21.8278
100161......................................................      21.5025      22.2994      22.3053      22.0508
100162......................................................      19.8748      20.1411      20.3110      20.1117
100165......................................................      18.5739      19.0388      22.6622      20.3299
100166......................................................      20.4228      20.0250      21.2309      20.5491
100167......................................................      21.8138      23.4075      23.2969      22.8605
100168......................................................      20.1260      20.1994      20.3167      20.2165
100169......................................................      20.7778      20.9506      20.3017      20.6703
100170......................................................      15.1167      18.5088      19.3005      17.5325
100172......................................................      15.1848      14.3446      14.8826      14.8099
100173......................................................      17.3416      18.5662      17.1337      17.6572
100174......................................................      20.5125      26.1826      21.9807      22.2819
100175......................................................      17.8237      18.1692      20.5442      19.0035
100176......................................................      24.6978      22.8604      24.3089      23.9493
100177......................................................      22.0034      24.4296      24.4284      23.5639
100179......................................................      20.9053      22.3015      23.0849      22.0467
100180......................................................      18.4754      20.2130      21.5388      20.0049
100181......................................................      24.5704      23.0800      18.9510      21.8206
100183......................................................      20.8579      24.6121      23.0654      22.6623
100187......................................................      20.6938      20.2533      20.8535      20.6013
100189......................................................      21.0102      21.3147      26.5962      23.0255
100191......................................................      18.4692      19.9879      21.0647      19.7731
100199......................................................      23.3713      21.7193            *      22.5030
100200......................................................      22.2575      22.4579      23.8729      22.8861
100203......................................................      18.8628            *            *      18.8628
100204......................................................      20.2049      20.8995      20.2193      20.4418
100206......................................................      20.3511      19.5710      20.1171      20.0138
100207......................................................      15.9173            *            *      15.9173
100208......................................................      20.8337      21.2117      20.7029      20.9220
100209......................................................      19.7329      22.4577      23.3903      21.8570
100210......................................................      19.1799      21.3575      21.8545      20.7662
100211......................................................      25.5277      20.6427      20.7516      21.9172
100212......................................................      25.3441      21.1187      21.1263      22.2176
100213......................................................      19.1238      20.6558      21.1818      20.2975

[[Page 39970]]

 
100217......................................................      19.8700      20.5909      22.7335      21.0211
100220......................................................      19.9121      21.2796      21.8246      20.9627
100221......................................................      22.2517      17.3965      21.2321      20.0812
100222......................................................      22.1958            *            *      22.1958
100223......................................................      18.7580      20.6302      20.2233      19.8755
100224......................................................      24.7023      20.0251      21.8628      21.8826
100225......................................................      20.6404      20.6802      21.5059      20.9335
100226......................................................      24.8641      20.6858      21.8808      22.2342
100228......................................................      23.6986      21.3168      20.8810      21.8300
100229......................................................      18.2070      19.6908      18.2350      18.7682
100230......................................................      20.6018      20.5051      22.5650      21.2357
100231......................................................      17.4002      17.9226      18.7526      18.0268
100232......................................................      17.3171      19.3491      19.8002      18.8267
100234......................................................      21.5763      20.9104      21.6360      21.3290
100235......................................................      17.6648      17.1622            *      17.4262
100236......................................................      21.8111      20.3766      20.6942      20.8937
100237......................................................      22.9344      22.0865      23.2408      22.7368
100238......................................................      17.6310      19.6367      20.8252      19.4032
100239......................................................      19.7605      21.3193      19.4481      20.1474
100240......................................................      17.9339      20.4340      21.0606      19.8014
100241......................................................      13.8344      14.7224      17.1063      15.0865
100242......................................................      17.1154      17.9260      18.6938      17.9097
100243......................................................      20.3838      21.2644      20.8041      20.8228
100244......................................................      17.4124      18.6227      20.5352      18.9148
100246......................................................      21.2160      19.6376      21.9247      20.8876
100248......................................................      21.5399      20.7007      21.2988      21.1681
100249......................................................      19.0243      19.2808      18.1397      18.8067
100252......................................................      17.8726      17.7778      19.8079      18.4729
100253......................................................      20.6014      21.3232      22.4778      21.5023
100254......................................................      20.9080      19.6598      19.5523      19.9896
100255......................................................      21.0224      25.2119      21.0284      22.2338
100256......................................................      23.5640      20.9356      21.2786      21.7690
100258......................................................      21.8764      21.3501      20.0300      21.0257
100259......................................................      19.8600      20.3815      21.1160      20.4723
100260......................................................      21.2224      21.0506      24.9183      22.3504
100262......................................................      19.5874      20.0433      21.0927      20.2558
100263......................................................      16.9012            *            *      16.9012
100264......................................................      17.6085      19.1556      19.9491      18.8967
100265......................................................      19.8571      18.8301      18.2291      18.8491
100266......................................................      17.7319      18.2993      19.3623      18.4763
100267......................................................      17.0986      20.1141      21.7430      19.6266
100268......................................................      23.5863      23.9249      24.0538      23.8633
100269......................................................      21.2047      21.6724      22.5114      21.8200
100270......................................................      19.8576      15.1462      16.7148      17.2012
100271......................................................      19.9208      20.4824      20.8695      20.4494
100275......................................................      21.3273      20.9188      21.4904      21.2374
100276......................................................      21.9797      22.3646      24.1022      22.8308
100277......................................................      16.1410      16.6255      19.7241      17.0041
100279......................................................      23.0213      22.9095      22.5879      22.8402
100280......................................................      16.5851      17.3676      18.1972      17.4129
100281......................................................      22.0202      22.4392      23.0142      22.5262
100282......................................................      19.7717      19.1978      18.4884      19.1653
100284......................................................            *            *      18.9448      18.9448
110001......................................................      18.0571      19.1971      20.1150      19.1086
110002......................................................      17.3674      17.1406      19.5158      18.0122
110003......................................................      16.9099      18.1168      17.1450      17.3940
110004......................................................      18.9468      19.5591      19.7733      19.4194
110005......................................................      19.2639      17.7348      22.4568      20.0888
110006......................................................      20.1273      20.7820      21.0601      20.6571
110007......................................................      23.4976      21.9505      25.2523      23.5682
110008......................................................      18.2642      22.0081      18.5265      19.5622
110009......................................................      14.8218      16.3069      17.4306      16.2843
110010......................................................      24.5493      23.3213      23.9104      23.9180

[[Page 39971]]

 
110011......................................................      18.2846      18.6144      18.9823      18.6368
110013......................................................      16.0264      16.2811      18.9160      17.1183
110014......................................................      16.1168      16.0658      18.1787      16.7192
110015......................................................      19.4769      21.2146      20.9926      20.5614
110016......................................................      15.2967      22.5321      14.2398      16.6540
110017......................................................      10.5399      13.1960      22.2537      15.3899
110018......................................................      21.0415      19.6064      22.1480      20.9298
110020......................................................      18.5251      18.3147      19.4617      18.7736
110023......................................................      18.6460      21.1994      22.0546      20.5885
110024......................................................      19.7923      20.7297      20.7345      20.4144
110025......................................................      18.6463      19.5749      20.4232      19.5033
110026......................................................      16.1414      17.2977      16.2484      16.5517
110027......................................................      14.6834      16.0642      14.7081      15.1696
110028......................................................      19.8894      20.1547      29.1670      22.3800
110029......................................................      20.0507      20.2906      21.2150      20.5454
110030......................................................      17.6785      18.8105      19.6412      18.7203
110031......................................................      21.5794      19.9482      20.0553      20.4598
110032......................................................      16.1859      15.7349      18.2014      16.6413
110033......................................................      21.4143      22.1879      25.6335      22.9577
110034......................................................      18.1882      19.6055      19.5554      19.0987
110035......................................................      21.1670      19.3795      22.7950      21.1658
110036......................................................      24.4181      22.2498      20.7284      22.3301
110038......................................................      16.3750      17.7060      17.7396      17.2680
110039......................................................      20.7710      20.6011      20.4998      20.6248
110040......................................................      16.4043      17.0743      16.8083      16.7529
110041......................................................      16.6927      18.8035      20.2755      18.6583
110042......................................................      20.6503      24.0153      25.2331      23.2575
110043......................................................      17.2175      20.1016      20.6150      19.2219
110044......................................................      19.5983      16.3624      17.2087      17.5794
110045......................................................      19.9445      20.2498      21.3049      20.4714
110046......................................................      19.2327      19.7377      21.4905      20.1167
110048......................................................      15.6463      16.3148      15.6113      15.8483
110049......................................................      14.2135      16.1817      16.8639      15.7669
110050......................................................      18.7516      20.7619      19.2291      19.5578
110051......................................................      15.7475      17.0070      17.2292      16.6496
110052......................................................      15.0562            *            *      15.0562
110054......................................................      19.2712            *      20.0549      19.6625
110056......................................................      16.4960      15.6202      17.7959      16.7305
110059......................................................      17.6984      16.6678      16.7990      17.0253
110061......................................................      13.7196      15.0367      16.3557      15.0889
110062......................................................      12.2107      18.8019      17.0053      16.1264
110063......................................................      17.9743      16.9612      18.5071      17.7965
110064......................................................      18.3368      18.9515      19.1203      18.8163
110065......................................................      13.3245      15.6771      16.3546      15.1604
110066......................................................      20.6502      21.0207      22.4189      21.3274
110069......................................................      18.3519      19.3109      20.9575      19.5384
110070......................................................      18.2264      21.0227      17.3438      18.7743
110071......................................................      14.8902      14.5984      18.8321      15.8863
110072......................................................      12.4303      12.7877      12.7625      12.6652
110073......................................................      15.1377      15.4261      16.4658      15.6663
110074......................................................      20.7572      21.3945      22.3769      21.5169
110075......................................................      17.0067      18.5199      20.1757      18.5793
110076......................................................      20.4430      21.2867      21.9798      21.2384
110078......................................................      24.7069      22.3718      24.0893      23.6954
110079......................................................      20.1385      21.0593      22.1070      21.0913
110080......................................................      23.4336      18.4768      19.1839      20.1449
110082......................................................      22.0078      23.8768      24.3140      23.4175
110083......................................................      21.3578      23.1219      23.1463      22.5746
110086......................................................      14.9756      18.2815      16.6374      16.5417
110087......................................................      20.5420      21.7773      22.7069      21.7189
110089......................................................      18.5761      18.5587      19.3855      18.8318
110091......................................................      21.3789      19.5114      21.5328      20.7784
110092......................................................      15.0890      17.3479      16.9725      16.4433

[[Page 39972]]

 
110093......................................................      14.8049            *      16.9827      15.7486
110094......................................................      13.8658      14.5641      16.9503      15.0650
110095......................................................      15.9478      16.4670      17.1195      16.5075
110096......................................................      16.3202      16.8541      17.4157      16.8647
110097......................................................      15.6164      15.5811      17.4558      16.1121
110098......................................................      14.0067      16.3532      16.0597      15.3226
110100......................................................      20.3764      18.6978      19.0764      19.3213
110101......................................................      11.7278      10.8187      18.8491      12.7872
110103......................................................      11.9352      13.6842      21.1837      14.0859
110104......................................................      15.3184      15.7781      15.9431      15.6829
110105......................................................      16.5196      16.8909      16.7775      16.7306
110107......................................................      17.3921      19.3609      19.3897      18.7335
110108......................................................      15.1401      19.7938      25.2161      19.3940
110109......................................................      16.3703      15.9359      16.4031      16.2270
110111......................................................      17.3215      18.5108      18.3951      18.0800
110112......................................................      19.1288      19.0619      19.8986      19.3117
110113......................................................      15.1896      16.8179      15.9532      15.9721
110114......................................................      15.1303      14.6888      16.4812      15.4358
110115......................................................      24.8332      43.9427      22.5049      27.8401
110118......................................................      15.3992      20.5368      19.7509      18.5122
110120......................................................      15.1878      15.2589      17.7452      15.9897
110121......................................................      15.5792      16.2711      19.3643      17.0685
110122......................................................      18.8497      21.1385      21.1469      20.3688
110124......................................................      17.1306      17.5732      18.3366      17.6460
110125......................................................      17.3254      19.1311      18.0090      18.1411
110127......................................................      13.7612      14.6143      20.3765      16.2641
110128......................................................      18.9705      18.1845      18.0835      18.4293
110129......................................................      18.1208      18.9388      19.0001      18.6851
110130......................................................      13.0779      16.0580      14.6011      14.6559
110132......................................................      15.0231      16.0419      16.3943      15.8158
110134......................................................      11.5583      12.5723      19.8639      15.1252
110135......................................................      17.0834      17.4380      17.3504      17.2967
110136......................................................      16.1680      18.0639      16.9629      16.8702
110140......................................................      17.8806      17.8870      17.7915      17.8571
110141......................................................      12.5051      13.2501      14.4935      13.4024
110142......................................................      12.3029      14.6144      13.9525      13.5947
110143......................................................      21.6898      20.1603      22.5926      21.5352
110144......................................................      17.9766      16.8685      17.5112      17.4397
110146......................................................      17.6068      16.1316      17.1835      16.9320
110149......................................................      22.2256      17.7535      32.1975      23.0615
110150......................................................      18.7724      20.2644      21.2909      20.0962
110152......................................................      14.7674      15.3996      15.1324      15.1011
110153......................................................      18.6862      19.2744      20.5068      19.4781
110154......................................................      14.8067      14.9636      17.3761      15.6408
110155......................................................      17.1370      15.5306      16.5146      16.3434
110156......................................................      15.3422      14.7477      16.3876      15.4698
110161......................................................      20.8657      21.7153      22.2861      21.6563
110163......................................................      18.2016      20.4202      18.6637      19.0060
110164......................................................      19.4946      20.2074      21.2160      20.2947
110165......................................................      18.9974      21.2577      20.8030      20.3401
110166......................................................      19.8510      20.5882      20.5049      20.3148
110168......................................................      19.8178      20.6646      21.8058      20.8014
110169......................................................      18.7189      20.6385      22.6648      20.4216
110171......................................................      20.0874      23.7893      25.5296      22.6284
110172......................................................      25.4390      23.3730      23.6803      24.1715
110174......................................................      14.2978      13.7339      14.6199      14.1905
110176......................................................      22.3971            *            *      22.3971
110177......................................................      19.5888      20.7187      21.2796      20.5272
110178......................................................      16.8555      18.8306            *      17.8083
110179......................................................      20.5161      22.7841      22.0767      21.7231
110181......................................................      13.7195      14.0941      12.9798      13.6399
110183......................................................      21.1797      23.3826      22.5148      22.3473
110184......................................................      20.9465      22.1970      22.1920      21.7791

[[Page 39973]]

 
110185......................................................      16.2487      16.7246      17.7925      16.9013
110186......................................................      17.3398      17.4287      18.3178      17.6984
110187......................................................      21.4462      20.1154      19.8419      20.4516
110188......................................................      20.0548      24.8376      23.7032      22.6465
110189......................................................      18.8627      22.2715      20.8786      20.7023
110190......................................................      19.4318      18.5728      18.3649      18.7761
110191......................................................      19.1065      20.2033      21.4033      20.2583
110192......................................................      20.7660      21.4951      21.0486      21.1064
110193......................................................      18.7807      20.6380      20.7867      20.0518
110194......................................................      15.0937      15.1480      14.8115      15.0165
110195......................................................      10.5227      13.9135      12.7261      12.3146
110198......................................................      26.1898      24.1999      24.8646      25.0493
110200......................................................      17.2129      18.1862      17.7744      17.7301
110201......................................................      19.2438      20.4699      20.9497      20.2248
110203......................................................      20.2958      26.8148      22.7453      23.1944
110204......................................................      20.5728      19.7317      30.7342      21.7754
110205......................................................      26.1154      21.1435      21.3617      22.7145
110207......................................................      12.8710      12.9727      14.7154      13.5335
110208......................................................      14.8907      15.1742      15.6161       5.1789
110209......................................................      20.4640      17.9190      18.6404      18.9942
110211......................................................      21.8226      20.9372      26.9151      23.1427
110212......................................................      12.6583      11.8545      14.3790      12.8830
110213......................................................      13.1976      14.3651            *      13.7453
110215......................................................            *      20.1928      18.1539      19.0047
110216......................................................            *            *      27.1878      27.1878
120001......................................................      26.7134      27.9213      29.0427      27.8237
120002......................................................      24.3780      25.0744      25.2021      24.8896
120003......................................................      23.8452      25.9059      23.9115      24.5394
120004......................................................      24.0456      23.9208      24.8632      24.2413
120005......................................................      20.5380      23.3975      24.1662      22.6197
120006......................................................      23.7151      25.0895      25.8943      24.8700
120007......................................................      23.2684      22.7200      22.8772      22.9509
120009......................................................      19.0216      17.4693      16.4485      17.5600
120010......................................................      25.3976      25.1480      24.1923      24.8868
120011......................................................      33.5459      35.0582      37.2759      35.3313
120012......................................................      22.5219      23.1144      21.8507      22.5391
120014......................................................      24.0467      22.8866      24.1208      23.6739
120015......................................................      29.0747      32.9906      42.6465      33.1800
120016......................................................      29.4104      27.9127      45.1899      31.1230
120018......................................................      25.6088      24.5031      31.1879      26.2841
120019......................................................      21.9199      22.9341      25.5659      23.4285
120021......................................................      19.4236      23.4508      23.1839      21.8865
120022......................................................      17.9306      21.7868      19.2614      19.5032
120024......................................................      22.2846      29.4808      32.2514      26.8486
120025......................................................      19.0197      20.1065      50.6376      21.3455
120026......................................................      23.2237      26.0787      25.1314      24.7719
120027......................................................      24.5549      24.7255      24.4535      24.5737
120028......................................................      23.4873      27.5023      27.0897      25.8902
130001......................................................      24.9511      18.8471      17.6306      20.1752
130002......................................................      16.1853      16.6620      16.9867      16.6200
130003......................................................      19.9499      21.7313      22.3430      21.3583
130005......................................................      20.1678      20.7169      21.2386      20.7149
130006......................................................      18.8705      19.3392      20.4614      19.5797
130007......................................................      19.8442      20.8338      21.8107      20.8426
130008......................................................      12.9177      12.5506      13.6018      12.9892
130009......................................................      18.2958      19.1837      15.9701      17.7296
130010......................................................      21.4325      17.6795      17.5119      18.7875
130011......................................................      19.0816      20.5031      20.1147      19.9190
130012......................................................      22.6153      22.9813      24.9976      23.5891
130013......................................................      19.2170      17.4038      15.1129      17.1523
130014......................................................      17.9836      18.9769      19.2107      18.7286
130015......................................................      15.2662      15.7233      18.5913      16.3849
130016......................................................      16.9987      17.3942      19.0516      17.7864

[[Page 39974]]

 
130017......................................................      16.8822      17.1710      19.6875      17.7220
130018......................................................      17.9651      19.7368      19.8425      19.2288
130019......................................................      17.2317      18.6648      19.1711      18.3322
130021......................................................      12.2562      12.8588      15.6155      13.6528
130022......................................................      19.5040      16.5270      18.9127      18.2241
130024......................................................      18.3789      19.3634      19.0703      18.9600
130025......................................................      15.2691      17.5213      16.4627      16.4881
130026......................................................      20.5535      21.5934      21.8106      21.3093
130027......................................................      20.7044      21.4279      20.5344      20.8883
130028......................................................      18.2074      19.1093      20.9674      19.4388
130029......................................................      20.3153      18.4263      18.7694      19.1364
130030......................................................      18.3981      17.8440      17.5759      17.9347
130031......................................................      17.6458      16.2397      16.7766      16.8967
130034......................................................      18.8164      16.9873      18.9483      18.2785
130035......................................................      20.4708      19.3478      20.7770      20.1943
130036......................................................      13.7942      13.7933      13.6362      13.7373
130037......................................................      17.7374      18.8071      18.6856      18.3986
130043......................................................      16.0686      16.5102      16.7904      16.4511
130044......................................................      13.1816      17.8160      13.4513      14.6424
130045......................................................      16.4655      16.0990      19.0208      17.0869
130048......................................................      15.0924      16.0899      16.7900      15.9311
130049......................................................      20.3928      20.3129      22.4440      21.0760
130054......................................................      17.7802      17.2729      17.7085      17.5766
130056......................................................      15.6551      14.6862      20.9476      16.5492
130058......................................................      17.7462            *            *      17.7462
130060......................................................      20.8508      21.8662      22.7399      21.8288
130061......................................................      16.7839      15.4006      14.7394      15.6929
130062......................................................      15.1086      16.5672      19.8157      17.1915
130063......................................................            *      15.9441      18.8024      17.8420
140001......................................................      15.4448      16.3372      17.7990      16.4814
140002......................................................      19.2575      19.0248      19.9284      19.3999
140003......................................................      18.0001      21.2886      17.8595      18.9466
140004......................................................      17.5200      15.7042      17.4574      16.8965
140005......................................................      10.8718      11.6127      12.3002      11.5858
140007......................................................      22.4015      22.9799      23.8585      23.0838
140008......................................................      21.2844      21.6548      22.1111      21.6838
140010......................................................      25.2227      31.8207      28.5635      28.3677
140011......................................................      17.2856      17.8676      18.6164      17.9499
140012......................................................      19.4406      23.0653      21.4374      21.2652
140013......................................................      17.3488      18.3060      19.6722      18.4213
140014......................................................      20.7563      22.4737      21.4042      21.5054
140015......................................................      15.0232      16.6735      17.6805      16.4314
140016......................................................      12.5363      13.1278      14.4938      13.3972
140018......................................................      21.4147      22.3070      22.4132      22.0345
140019......................................................      15.3435      16.6548      16.4254      16.1654
140024......................................................      14.6674      16.8271      15.3782      15.5912
140025......................................................      16.9489      16.9462      18.5135      17.4713
140026......................................................      15.9557      16.6612      18.3220      16.9446
140027......................................................      17.5023      18.7553      19.2149      18.5013
140029......................................................      21.0358      22.8322      26.0833      23.2140
140030......................................................      22.4414      21.9475      23.1760      22.5308
140031......................................................      15.9442      19.5731      17.6067      17.6942
140032......................................................      17.3363      18.1058      19.0383      18.1645
140033......................................................      22.5583      24.1722      25.1639      23.9291
140034......................................................      19.1482      19.5278      19.8792      19.5183
140035......................................................      12.9963      15.2649      15.5040      14.5633
140036......................................................      17.0419      18.5771      19.1076      18.2935
140037......................................................      12.5012      13.0764      14.1083      13.2105
140038......................................................      17.6094      18.3035      18.4948      18.1352
140040......................................................      16.2462      19.9267      16.7450      17.5895
140041......................................................      17.2829      17.6582      18.5952      17.8248
140042......................................................      15.6092      15.4095      15.8892      15.6354
140043......................................................      18.9464      19.4683      20.1176      19.5022

[[Page 39975]]

 
140045......................................................      20.6541      15.5807      17.7799      17.9528
140046......................................................      16.4621      18.9763      18.6371      18.0097
140047......................................................      16.3298      17.1539      13.3610      15.4382
140048......................................................      20.5773      24.0913      23.9545      22.8943
140049......................................................      21.5937      28.4958      26.9483      25.7338
140051......................................................      20.8455      23.8264      24.0796      22.8956
140052......................................................      19.6045      19.6409      17.9571      19.0338
140053......................................................      17.8218      19.1892      19.9620      18.9702
140054......................................................      26.1497      22.1921      23.1576      23.7695
140055......................................................      14.8031      16.3404      14.3603      15.1391
140058......................................................      17.2716      17.4927      18.6861      17.8100
140059......................................................      15.3934      15.0195            *      15.1978
140061......................................................      15.9612      17.3012      18.2039      17.1185
140062......................................................      27.0912      28.0877      28.5304      27.9131
140063......................................................      22.3882      25.3641      29.1453      25.1919
140064......................................................      19.2549      19.1023      18.9379      19.0960
140065......................................................      23.1610      24.1128      25.3336      24.1516
140066......................................................      16.1759      17.3902      13.6491      15.5770
140067......................................................      18.4031      19.3267      19.5292      19.0846
140068......................................................      18.8739      19.9691      21.6188      20.0995
140069......................................................      16.1453      16.7544      17.3879      16.7949
140070......................................................      19.2995      22.9678      22.7153      21.2244
140074......................................................      19.0077      19.3504      21.6052      19.9120
140075......................................................      22.5083      21.6313      21.6434      21.9439
140077......................................................      16.6447      17.5305      17.3647      17.1709
140079......................................................      21.9205      23.3020      23.6928      22.9153
140080......................................................      20.9999      21.0739      22.1968      21.3875
140081......................................................      15.5103      16.2247      16.9808      16.1897
140082......................................................      22.6227      23.8960      29.7262      24.9037
140083......................................................      18.1349      19.3145      21.0330      19.4951
140084......................................................      20.0133      20.9709      22.3467      21.0939
140086......................................................      17.3717      18.3803      19.1613      18.3356
140087......................................................      18.3639      16.1009      17.1147      17.1839
140088......................................................      24.2568      25.2369      25.4176      24.9650
140089......................................................      17.2086      17.6366      18.3157      17.7164
140090......................................................      23.5888      26.4325      26.9364      25.3709
140091......................................................      20.7039      20.9018      21.9322      21.1441
140093......................................................      19.1469      18.2899      20.1528      19.1437
140094......................................................      20.6129      21.4709      21.9383      21.3227
140095......................................................      21.5376      24.0549      24.2859      23.1400
140097......................................................      16.8997      17.5081      21.1719      18.4160
140100......................................................      19.0588      21.3581      23.1399      21.1571
140101......................................................      26.0894      21.5473      21.4211      22.7744
140102......................................................      15.0777      17.1500      17.5729      16.5644
140103......................................................      17.8586      19.2783      18.1303      18.4145
140105......................................................      20.9068      22.6573      22.8944      22.1275
140107......................................................      12.7573      13.7533      11.8383      12.6800
140108......................................................      28.6028      25.4742      26.9971      26.9964
140109......................................................      15.4724      15.7465      14.5498      15.2467
140110......................................................      18.8112      19.1822      19.2888      19.0728
140112......................................................      16.2399      17.6856      17.6974      17.1885
140113......................................................      17.9151      19.0592      19.5584      18.8265
140114......................................................      20.4808      21.1639      21.0976      20.9149
140115......................................................      20.0939      21.1926      21.0433      20.7564
140116......................................................      21.8290      23.1177      23.8993      22.9520
140117......................................................      19.6445      21.5671      21.4876      20.8750
140118......................................................      23.0797      23.5952      24.3260      23.6559
140119......................................................      26.5042      29.1419      27.9145      27.8197
140120......................................................      14.8375      18.0743      17.9716      16.8874
140121......................................................       9.5268      16.0397      16.6993      13.2257
140122......................................................      23.7473      24.6470      26.1270      24.8110
140124......................................................      26.9706      27.1906      27.9813      27.3549
140125......................................................      17.0974      17.6759      16.9516      17.2453

[[Page 39976]]

 
140127......................................................      19.4259      19.8973      20.0489      19.7765
140128......................................................      17.6751      19.4955      23.1327      20.0664
140129......................................................      15.2494      18.2639      20.2868      17.8627
140130......................................................      23.7682      22.2285      23.4298      23.1296
140132......................................................      23.0443      23.5475      23.3054      23.2992
140133......................................................      19.9083      21.4090      21.4166      20.8761
140135......................................................      17.6927      17.8100      17.3985      17.6268
140137......................................................      16.5141      16.8969      18.6330      17.3470
140138......................................................      14.5877      16.7420      17.1968      16.2121
140139......................................................      16.5794      14.0619      11.0397      13.5138
140140......................................................      15.2985      17.8243      17.6845      16.9747
140141......................................................      15.1782      17.5204      19.1097      17.2133
140143......................................................      18.7616      19.1862      19.0810      19.0186
140144......................................................      19.7913      21.3245      22.2864      21.1022
140145......................................................      16.6111      17.5471      18.1788      17.4556
140146......................................................      23.7400      21.9573      19.9704      21.7285
140147......................................................      24.8191      16.1336      18.8049      19.2135
140148......................................................      19.5026      18.6598      18.7730      18.9637
140150......................................................      27.8485      27.3378      24.7976      26.6536
140151......................................................      19.3016      21.3896      20.0310      20.2086
140152......................................................      22.4270      24.6333      25.6011      24.1041
140155......................................................      17.3131      19.9738      20.2778      19.1103
140158......................................................      22.2666      22.7639      22.7988      22.5990
140160......................................................      17.8822      17.7691      17.7921      17.8132
140161......................................................      19.0448      20.0948      20.3799      19.8258
140162......................................................      18.4167      19.6464      20.3452      19.4479
140164......................................................      18.6120      18.7806      18.6589      18.6860
140165......................................................      15.4186      14.9156      14.7223      15.0080
140166......................................................      17.5434      17.5496      18.3833      17.8149
140167......................................................      16.5671      17.1479      17.6525      17.1325
140168......................................................      16.4638      16.6770      17.7453      16.9752
140170......................................................      14.1360      16.1621      16.4107      15.5211
140171......................................................      14.7316      14.1637      15.0237      14.6354
140172......................................................      20.7982      23.8431      23.6262      22.5610
140173......................................................      18.4788      15.1487      16.3924      16.7054
140174......................................................      19.9216      20.5339      35.9320      23.2157
140176......................................................      21.4129      23.2866      24.5338      23.0397
140177......................................................      18.1692      18.2648      15.0827      17.1204
140179......................................................      22.6989      21.1948      21.9859      21.9622
140180......................................................      23.2536      22.4548      22.7996      22.8262
140181......................................................      20.5461      20.8709      21.9864      21.1001
140182......................................................      20.7013      22.0170      28.9515      23.2649
140184......................................................      14.9763      17.8155      17.2401      16.6194
140185......................................................      17.3616      17.6514      18.2867      17.7696
140186......................................................      18.9878      22.7890      23.5034      21.7241
140187......................................................      17.6910      17.9201      18.3331      17.9863
140188......................................................      14.8373      15.2479      16.1907      15.4001
140189......................................................      19.0791      21.0616      20.6627      20.2758
140190......................................................      15.8770      16.3366      17.5263      16.5534
140191......................................................      24.7368      25.8835      25.2628      25.2833
140193......................................................      15.5196      15.8022      17.4057      16.2409
140197......................................................      17.9828      18.6394      19.3774      18.6752
140199......................................................      18.8333      18.3507      18.0450      18.4044
140200......................................................      21.6508      21.5220      21.7680      21.6496
140202......................................................      22.1800      22.1939      23.7955      22.7597
140203......................................................      20.7854      19.9194      21.0848      20.5915
140205......................................................      17.2369      17.4751      20.0784      18.0505
140206......................................................      20.5096      21.3295      22.5109      21.4570
140207......................................................      20.2048      21.9779      22.3905      21.3996
140208......................................................      23.9441      25.9900      26.2527      25.3856
140209......................................................      17.7889      18.1206      20.1557      18.6405
140210......................................................      12.6648      15.6899      14.8248      14.4319
140211......................................................      20.9615      21.8891      22.6265      21.8594

[[Page 39977]]

 
140213......................................................      26.2041      27.0645      24.9892      26.0871
140215......................................................      14.4544      15.9949      15.2893      15.2456
140217......................................................      23.3192      24.8229      25.7329      24.5914
140218......................................................      15.0750      14.9459      14.9851      15.0038
140220......................................................      16.7341      17.6370      17.8450      17.4280
140223......................................................      21.4725      24.9249      24.9017      23.6377
140224......................................................      22.9945      25.8668      32.8292      26.7133
140228......................................................      18.6731      19.6988      20.1688      19.5400
140230......................................................      16.5979      18.0918      18.2983      17.6740
140231......................................................      21.6062      23.9176      24.5019      23.4404
140233......................................................      18.3703      19.4542      21.2333      19.6539
140234......................................................      18.7156      18.9945            *      18.8552
140236......................................................      13.1341            *      12.9253      13.0112
140239......................................................      18.8785      18.8127      20.3745      19.3689
140240......................................................      24.2141      23.6860      24.6949      24.1989
140242......................................................      22.6679      24.5428      25.2317      24.1792
140245......................................................      15.5554      13.4839      14.2481      14.3597
140246......................................................      12.8238      13.4639      11.6267      12.5798
140250......................................................      23.4127      25.0876      23.6449      24.0578
140251......................................................      20.5813      21.4385      21.9435      21.3153
140252......................................................      24.4856      25.2246      25.0220      24.9139
140253......................................................      16.7356      18.5511      19.5858      18.2440
140258......................................................      21.1321      23.2973      25.3622      23.2691
140271......................................................      15.3606      15.5079      12.0079      14.1590
140275......................................................      17.9597      20.1699      23.8171      20.5857
140276......................................................      23.7163      26.6777      25.3134      25.2323
140280......................................................      18.8420      20.2360      18.8300      19.2649
140281......................................................      23.3433      24.0192      25.2719      24.2302
140285......................................................      14.7087      18.1181      18.5916      17.2227
140286......................................................      19.9500      20.3735      26.1290      22.0885
140288......................................................      21.8213      25.2327      24.4331      23.7989
140289......................................................      16.4542      17.1388      18.1747      17.3055
140290......................................................      21.2384      21.1784      22.8590      21.7763
140291......................................................      22.4352      25.0911      24.9537      24.1790
140292......................................................      22.7136      20.8560      21.9950      21.8371
140294......................................................      17.5226      17.7226      17.7301      17.6645
140297......................................................      21.4692            *            *      21.4692
140300......................................................      23.2560      25.3662      27.8436      25.5898
150001......................................................      21.6990      22.8109      24.0620      22.8643
150002......................................................      18.7568      19.3401      20.7651      19.6416
150003......................................................      19.3117      19.7661      20.8636      19.9824
150004......................................................      19.7020      20.3685      21.2449      20.4349
150005......................................................      18.9964      20.6260      21.6806      20.4380
150006......................................................      20.0433      20.8158      20.6523      20.5130
150007......................................................      19.5255      20.1826      20.6635      20.1487
150008......................................................      20.9684      21.4545      21.8457      21.4285
150009......................................................      18.2168      18.7073      19.0030      18.6289
150010......................................................      18.4776      21.7125      20.5570      20.1836
150011......................................................      19.1957      18.3742      18.3275      18.6280
150012......................................................      20.5193      22.4751      22.1402      21.6785
150013......................................................      16.0043      17.0352      16.9327      16.6522
150014......................................................      21.2812      22.0143      21.5168      21.6212
150015......................................................      22.0452      22.5409      21.9037      22.1546
150017......................................................      18.8898      18.7664      19.5339      19.0694
150018......................................................      19.5612      20.4947      21.0496      20.3869
150019......................................................      15.2892      16.6327      17.8585      16.5672
150020......................................................      14.4592      15.1120      16.6600      15.3745
150021......................................................      19.0162      19.5096      21.5944      20.0447
150022......................................................      17.9206      19.1555      17.9222      18.3309
150023......................................................      18.6641      18.3598      19.3412      18.8110
150024......................................................      17.8311      18.4140      19.2295      18.4561
150025......................................................      18.1490      17.7007      20.2750      18.6347
150026......................................................      20.5085      18.8417      22.4978      20.5355

[[Page 39978]]

 
150027......................................................      16.4846      17.3284      18.0335      17.2600
150029......................................................      21.7414      23.0546      23.2454      22.7440
150030......................................................      17.3296      17.9992      19.2406      18.1943
150031......................................................      18.0060      17.2429      18.3463      17.8675
150032......................................................      20.6391            *            *      20.6391
150033......................................................      21.6854      21.8768      22.6741      22.0835
150034......................................................      21.2868      22.1317      23.1533      22.1845
150035......................................................      19.8177      20.4477      21.2374      20.5107
150036......................................................      20.3848      20.8692      21.4567      20.9448
150037......................................................      17.7868      21.7109      24.4611      21.1306
150038......................................................      20.2503      21.2193      22.0572      21.2025
150039......................................................      17.4919      18.4729      19.6215      18.5025
150042......................................................      17.1241      18.1632      20.2221      18.3947
150043......................................................      17.9834      19.0120      20.1741      18.9948
150044......................................................      17.6432      18.4381      19.1309      18.4093
150045......................................................      17.0395      16.8121      18.1670      17.3563
150046......................................................      17.3210      17.6342      18.2543      17.7460
150047......................................................      24.8819      19.7441      22.0145      22.1013
150048......................................................      16.9573      19.3329      19.1648      18.5048
150049......................................................      16.8529      17.0141      18.6451      17.4705
150050......................................................      17.1442      16.8354      17.7354      17.2410
150051......................................................      18.1990      19.0130      19.7257      18.9710
150052......................................................      15.3618      15.8590      17.3750      16.2411
150053......................................................      18.7463      19.1421      18.8632      18.9165
150054......................................................      17.3296      17.3825      18.3916      17.7528
150056......................................................      23.2991      22.4087      21.5774      22.2457
150057......................................................      16.8630      16.5882      16.9736      16.8076
150058......................................................      20.9537      20.8178      22.1409      21.3058
150059......................................................      20.8004      21.2535      22.7360      21.5830
150060......................................................      16.0098      17.0743      18.6159      17.2538
150061......................................................      17.2141      17.3887      19.7968      18.0770
150062......................................................      18.4110      20.5415      20.8274      20.0239
150063......................................................      21.0899      22.0925      22.6525      21.9213
150064......................................................      17.0309      18.1400      20.3865      18.5718
150065......................................................      19.0051      19.8913      21.2153      20.0425
150066......................................................      14.5977      15.3373      19.5313      16.4634
150067......................................................      17.0829      18.2926      18.8862      18.0821
150069......................................................      17.3918      21.5310      23.3969      20.9447
150070......................................................      17.1992      17.9260      18.0827      17.7417
150071......................................................      14.7306      13.4760      13.5111      13.9122
150072......................................................      16.1091      16.2054      15.0765      15.7702
150073......................................................      19.0292      22.2968            *      20.5664
150074......................................................      18.8597      20.4175      20.2305      19.8210
150075......................................................      14.9786      15.5603      16.7532      15.7414
150076......................................................      22.3407      22.9382      22.6424      22.6387
150077......................................................      17.5750            *            *      17.5750
150078......................................................      19.0096      19.2718      19.9668      19.4018
150079......................................................      15.4545      17.2436      18.2051      16.9085
150082......................................................      17.8796      17.5265      17.8381      17.7489
150084......................................................      22.9159      23.2506      24.3107      23.4933
150086......................................................      17.3442      18.9735      18.3838      18.2534
150088......................................................      19.4475      18.9869      20.3366      19.5726
150089......................................................      22.9458      23.8791      22.1725      22.9671
150090......................................................      19.0595      20.7726      21.0945      20.2459
150091......................................................      19.8912      20.4053      22.4640      20.9087
150092......................................................      15.9174      16.7434      16.9179      16.5364
150094......................................................      18.3410      16.5788      17.5244      17.5067
150095......................................................      17.1187      17.1324      19.2749      17.7838
150096......................................................      20.0281      23.2764      20.8204      21.3056
150097......................................................      18.3103      19.3802      19.7751      19.1545
150098......................................................      14.2953      15.0943      15.2829      14.8856
150099......................................................      18.9718      22.4229            *      20.3545
150100......................................................      17.4776      18.4148      19.8066      18.6620

[[Page 39979]]

 
150101......................................................      17.5554      16.4604      20.6209      18.1130
150102......................................................      11.5034      19.7426      23.7180      17.1422
150103......................................................      17.3064      18.4781      18.7036      18.2137
150104......................................................      17.2642      17.6981      20.0765      18.3399
150105......................................................      19.1709      20.0431      22.4412      20.4692
150106......................................................      18.9097      16.1510      16.8714      17.2294
150109......................................................      18.2289      18.8077      19.9066      18.9623
150110......................................................      18.5752      18.6627      21.9336      19.5289
150111......................................................      16.1707      18.4556      19.2355      17.8619
150112......................................................      19.8155      20.4109      20.5253      20.2569
150113......................................................      19.1988      20.3780      19.6603      19.7455
150114......................................................      16.9638      19.5183      17.9877      18.1743
150115......................................................      17.0627      17.4315      18.4844      17.6591
150122......................................................      19.3545      18.7139      17.7867      18.6097
150123......................................................      15.1552      14.1105      14.0508      14.4522
150124......................................................      15.0706      14.6245      15.9487      15.2180
150125......................................................      20.3198      20.6735      21.3311      20.7806
150126......................................................      20.2958      21.3697      20.6857      20.7640
150127......................................................      22.8129      17.1994      17.0052      18.8048
150128......................................................      19.9205      18.5100      19.5576      19.3346
150129......................................................      23.4718      24.7711      28.6211      25.2796
150130......................................................      16.4144      18.1971      18.4846      17.6635
150132......................................................      19.4805      20.1684      20.9443      20.1836
150133......................................................      16.4910      17.3966      18.4250      17.4061
150134......................................................      17.0612      19.2526      19.3632      18.5912
150136......................................................      19.2819      20.1245      21.8097      20.3987
150145......................................................            *      16.6851            *      16.6851
150146......................................................            *            *      19.0204      19.0204
160001......................................................      19.0279      18.6035      19.0085      18.8767
160002......................................................      15.3724      15.9534      16.6003      15.9668
160003......................................................      15.7747      16.0862      16.2208      16.0221
160005......................................................      15.2320      17.6153      17.9405      16.9144
160007......................................................      15.6638      13.2101      15.1738      14.6237
160008......................................................      14.9698      15.9742      16.6193      15.8477
160009......................................................      16.0919      16.8391      17.9886      16.9591
160012......................................................      16.5409      16.4827      16.7112      16.5761
160013......................................................      17.0602      18.3996      18.6304      18.0298
160014......................................................      15.0861      15.9086      16.7146      15.8981
160016......................................................      18.3710      19.6322      19.9747      19.3376
160018......................................................      14.1634      14.5946      15.6141      14.7975
160020......................................................      14.4135      15.4712      15.5384      15.1417
160021......................................................      15.4860      16.5049      16.7617      16.2368
160023......................................................      14.2015      15.0665      15.0099      14.7723
160024......................................................      18.9548      19.7050      19.4764      19.3806
160026......................................................      18.6624      18.8379      19.5260      19.0040
160027......................................................      15.7403      16.3477      16.9417      16.3376
160028......................................................      20.5416      19.9595      21.0000      20.4893
160029......................................................      20.4003      20.4678      21.3457      20.7382
160030......................................................      17.9860      19.9508      19.6182      19.1837
160031......................................................      15.2831      15.2448      16.1267      15.5484
160032......................................................      16.1820      17.3202      18.3168      17.2888
160033......................................................      18.3736      18.8673      18.8859      18.7219
160034......................................................      14.5053      15.0019      16.5957      15.3739
160035......................................................      15.9199      15.2211      16.3991      15.8029
160036......................................................      19.1984      17.8849      17.4558      18.1820
160037......................................................      18.3968      19.0532      19.5045      18.9883
160039......................................................      17.6272      17.4758      17.8647      17.6551
160040......................................................      16.8295      18.1949      18.0667      17.6917
160041......................................................      15.4700      16.7850      17.4435      16.5782
160043......................................................      15.6261      15.6909      14.8564      15.3356
160044......................................................      16.0385      16.7439      17.8323      16.9072
160045......................................................      20.1154      20.1236      20.0611      20.1010
160046......................................................      14.7672      14.5655      16.2737      15.1831

[[Page 39980]]

 
160047......................................................      16.6926      18.3593      19.0787      18.0537
160048......................................................      13.1417      14.6144      15.6856      14.5140
160049......................................................      13.3614      14.5457      15.5673      14.5017
160050......................................................      16.4161      17.4912      17.7878      17.2198
160051......................................................      14.2660      14.6400      16.4261      15.1036
160052......................................................      17.5509      18.0941      21.7647      19.2313
160054......................................................      15.7093      16.1753      16.1981      16.0321
160055......................................................      14.0647      14.7600      15.1674      14.6539
160056......................................................      15.3758      16.1575      17.0172      16.1537
160057......................................................      17.4101      18.1776      19.1378      18.2553
160058......................................................      20.3402      21.1159      22.1061      21.1598
160060......................................................      15.9527      16.0436      17.2825      16.3968
160061......................................................      17.5707      17.3215      17.0938      17.3350
160062......................................................      14.4433      17.8086      17.4388      16.4393
160063......................................................      16.2960      16.8834      16.3583      16.5061
160064......................................................      19.9135      20.5496      22.2131      20.9171
160065......................................................      16.5087      16.9373      17.1043      16.8758
160066......................................................      16.2651      17.1875      17.9971      17.1716
160067......................................................      17.8551      17.8514      16.7833      17.4322
160068......................................................      15.8526      17.9892      19.0572      17.5565
160069......................................................      18.4857      19.7280      19.1640      19.1095
160070......................................................      15.6647      16.7017      18.4588      16.9299
160072......................................................      14.1920      14.9536      14.4141      14.5422
160073......................................................      15.0526      11.8261      11.4997      12.6736
160074......................................................      16.4772      19.5092      17.9513      18.0038
160075......................................................      17.8870      19.4948      18.4613      18.6342
160076......................................................      17.3086      17.9381      17.8824      17.7060
160077......................................................      11.4028      12.8826      13.6658      12.6451
160079......................................................      17.7050      17.6187      18.6333      17.9899
160080......................................................      17.8143      18.6687      19.4925      18.6704
160081......................................................      16.5150      17.0052      17.4466      17.0164
160082......................................................      18.7630      19.6499      19.5322      19.3143
160083......................................................      18.4078      20.6189      19.7542      19.5937
160085......................................................      18.5510      18.0063      21.2557      19.2281
160086......................................................      16.4558      17.3271      17.5308      17.0998
160088......................................................      17.5331      20.2331      22.3655      19.9346
160089......................................................      16.7419      16.9538      17.3449      17.0079
160090......................................................      16.6002      17.1090      17.9614      17.2461
160091......................................................      12.1893      12.8516      14.2573      13.0755
160092......................................................      15.7979      15.5011      17.0633      16.0971
160093......................................................      15.9525      17.7457      18.5675      17.5141
160094......................................................      16.5609      18.7653      17.6094      17.6731
160095......................................................      14.2649      15.1895      15.2722      14.9322
160097......................................................      15.2079      15.9263      16.6790      15.9380
160098......................................................      15.5385      16.3135      16.8670      16.2509
160099......................................................      13.7864      13.9053      15.0880      14.2533
160101......................................................      17.8654      18.3705      18.9788      18.3824
160102......................................................      18.3631      18.8765      20.1161      19.0875
160103......................................................      17.1519      17.0973      18.2741      17.4869
160104......................................................      19.7387      18.8301      17.4829      18.7797
160106......................................................      16.6624      16.9639      17.3474      16.9910
160107......................................................      16.5622      18.0634      18.0097      17.5762
160108......................................................      15.4183      16.0529      16.7779      16.0861
160109......................................................      16.4885      16.5593      17.9873      16.9740
160110......................................................      18.8056      19.1420      20.6215      19.5351
160111......................................................      13.1689      14.1644      14.9965      14.0808
160112......................................................      16.2829      16.8332      17.2450      16.7911
160113......................................................      14.5838      14.7097      15.4834      14.9308
160114......................................................      15.5812      16.1423      16.5006      16.0651
160115......................................................      15.7566      15.8995      16.5654      16.0764
160116......................................................      16.6927      16.9534      16.6993      16.7818
160117......................................................      17.2914      17.9410      18.7615      17.9848
160118......................................................      15.8351      17.2523      19.4472      17.5046

[[Page 39981]]

 
160120......................................................      12.5642      10.5992      15.6789      12.4454
160122......................................................      18.5214      18.9252      18.1469      18.5357
160124......................................................      17.1642      18.0908      19.1600      18.1198
160126......................................................      17.7397      17.8142      19.4903      18.3068
160129......................................................      15.8914      16.7131      17.2112      16.5953
160130......................................................      15.4477      16.0528      15.6666      15.7242
160131......................................................      14.6874      15.4898      16.0424      15.4292
160134......................................................      13.3246      13.4743      15.3012      14.0359
160135......................................................      16.3294      18.2682      18.7711      17.7744
160138......................................................      15.7076      16.8699      17.1491      16.5906
160140......................................................      18.7962      18.4007      18.5630      18.5823
160142......................................................      16.1372      16.2875      18.1467      16.8318
160143......................................................      15.9240      16.6154      17.4497      16.6799
160145......................................................      15.1745      13.9152      16.9092      15.2763
160146......................................................      16.3532      16.6024      17.7010      16.8728
160147......................................................      18.3917      17.4880      19.4041      18.3938
160151......................................................      15.7384      16.8257      17.2177      16.5833
160152......................................................      15.2179      15.6170      15.9500      15.5914
160153......................................................      19.6927      20.2316      21.2085      20.3741
170001......................................................      17.4383      17.9304      17.9218      17.7616
170004......................................................      13.0635      15.0636      16.1442      14.7434
170006......................................................      19.3075      17.2192      17.5982      17.9438
170008......................................................      13.9009      14.9124      16.8412      15.1327
170009......................................................      19.5867      20.7795      23.1349      21.2143
170010......................................................      17.8995      18.7384      19.4584      18.6890
170012......................................................      16.7886      17.8719      18.4432      17.7137
170013......................................................      17.8949      18.6454      19.4667      18.6963
170014......................................................      17.3379      17.9349      18.4931      17.9333
170015......................................................      15.8887      16.5750      17.1302      16.5216
170016......................................................      19.6393      19.2130      20.0675      19.6307
170017......................................................      17.8690      17.7958      19.5994      18.4143
170018......................................................      14.2759      15.2984      15.3237      14.9817
170019......................................................      16.6611      15.2094      16.9362      16.2597
170020......................................................      16.1460      17.3400      18.1325      17.2351
170022......................................................      17.9383      18.5309      19.1888      18.5543
170023......................................................      19.3585      19.1351      19.2441      19.2444
170024......................................................      13.0566      13.6803      14.3604      13.6835
170025......................................................      16.3716      17.8667      18.7182      17.6087
170026......................................................      13.3122      15.0470      14.8974      14.3412
170027......................................................      16.3859      17.3604      17.8690      17.2095
170030......................................................      15.2397      14.6530      15.9282      15.2488
170031......................................................      13.4670      13.9601      14.2151      13.8715
170032......................................................      14.4835      15.6093      16.3449      15.4817
170033......................................................      16.0529      16.4059      19.1952      17.1087
170034......................................................      14.6349      15.8202      16.9586      15.7633
170035......................................................      15.6240      18.5885      17.0945      17.0832
170036......................................................      14.1732            *            *      14.1732
170038......................................................      14.2092      14.7776      13.8582      14.2922
170039......................................................      14.2952      15.8635      17.0774      15.7642
170040......................................................      20.1419      21.6440      21.0617      20.9374
170041......................................................      11.4691      11.7566      12.4488      11.8690
170044......................................................      14.7801      15.3011      17.3254      15.8168
170045......................................................      12.1066      14.0875      25.8331      16.7874
170049......................................................      18.5821      19.9415      20.7921      19.8083
170051......................................................      14.1572      15.0889      16.4851      15.2703
170052......................................................      14.6176      15.0108      15.2283      14.9500
170053......................................................       9.0407      16.5102      14.6133      11.9759
170054......................................................      12.7655      14.4353      14.6354      13.9214
170055......................................................      14.9875      16.9800      18.2607      16.7698
170056......................................................      14.8656      17.0442      18.3550      16.8283
170057......................................................      15.0892      13.0007            *      13.9776
170058......................................................      18.3389      18.6983      19.5415      18.8159
170060......................................................      17.2271      17.3482      18.9853      17.7512

[[Page 39982]]

 
170061......................................................      14.1380      15.6527      15.0258      14.9459
170063......................................................      11.3284      12.8082      14.1185      12.6216
170064......................................................      12.4183            *            *      12.4183
170066......................................................      14.4790      15.5322      16.2891      15.4168
170067......................................................      12.7846      14.7492      14.9921      14.1535
170068......................................................      15.8175      15.1790      17.0022      15.9795
170070......................................................      12.8158      14.2445      14.0627      13.7083
170072......................................................      13.3379      12.6329      12.7709      12.9159
170073......................................................      16.4690      17.5368      17.7056      17.2186
170074......................................................      14.4009      17.5537      17.3699      16.4326
170075......................................................      11.2598      12.4212      13.6816      12.5950
170076......................................................      13.5820      14.5866      14.6109      14.2394
170077......................................................      12.7244      13.5235      13.9104      13.3651
170079......................................................      14.2859      13.5261      11.5902      13.1470
170080......................................................      12.2012      12.6014      14.8293      13.1562
170081......................................................      12.5122      13.8077      14.6823      13.7421
170082......................................................      12.3902      12.8563      13.7462      12.9854
170084......................................................      12.1611      12.5410      13.0519      12.5742
170085......................................................      14.5069      15.4518      17.5422      15.9150
170086......................................................      19.8496      20.4068      19.7182      19.9991
170088......................................................      11.7505      13.4542      13.4860      12.9031
170089......................................................      18.0823      18.8136      15.4860      17.4574
170090......................................................      11.2747      11.9147      10.9444      11.3947
170092......................................................      12.8507            *            *      12.8507
170093......................................................      12.7780      13.5490      14.0276      13.4193
170094......................................................      17.7091      20.1985      21.2035      19.6936
170095......................................................      15.7469      15.5463      15.3532      15.5482
170097......................................................      15.8504      16.4608      17.7540      16.7203
170098......................................................      14.1026      15.5259      16.6210      15.4425
170099......................................................      13.5509      13.6033      14.3370      13.8072
170100......................................................      14.4700            *            *      14.4700
170101......................................................      12.8847      14.5629      18.0143      14.7718
170102......................................................      13.2434      13.6321      14.2447      13.7065
170103......................................................      16.6578      17.2844      17.9530      17.2887
170104......................................................      19.7645      20.6182      21.0049      20.4661
170105......................................................      15.9290      16.5408      16.7403      16.4083
170106......................................................      14.6773      18.5479      17.7467      16.9030
170109......................................................      16.9421      17.2629      16.9782      17.0622
170110......................................................      15.5549      16.9823      18.5731      17.1658
170112......................................................      13.3908      14.3855      15.4049      14.4270
170113......................................................      13.3935      13.9038      14.6486      13.9920
170114......................................................      14.5116      14.4545      16.2645      15.0138
170115......................................................      12.6815      12.6997      12.9216      12.7709
170116......................................................      15.7566      16.8714      18.1830      16.9494
170117......................................................      15.2818      15.7875      16.8237      15.8968
170119......................................................      13.9673      15.1990      15.2708      14.7822
170120......................................................      16.2122      17.6748      17.4917      17.1241
170122......................................................      20.1266      20.0615      21.1769      20.4366
170123......................................................      21.4168      23.1697      23.6534      22.7009
170124......................................................      10.2089      11.1249      15.0596      11.8247
170126......................................................      12.1268      12.8096      13.5736      12.8129
170128......................................................      14.9919      14.8891      14.1676      14.6301
170131......................................................      13.0978      10.1000            *      11.3849
170133......................................................      17.1103      18.0243      18.8119      17.9917
170134......................................................      14.2252      14.1085      14.6799      14.3402
170137......................................................      17.4151      17.8290      19.3118      18.1884
170139......................................................      13.3896      14.1967      14.3001      13.9545
170142......................................................      17.3234            *      17.7134      17.5177
170143......................................................      15.8802      15.6509      16.0415      15.8575
170144......................................................      16.0860      19.0929      20.4392      18.4073
170145......................................................      16.7499      17.1837      19.0142      17.6442
170146......................................................      19.9725      20.9075      21.7919      20.9132
170147......................................................      16.2829      22.3017      17.6717      18.6905

[[Page 39983]]

 
170148......................................................      17.2497      16.9183      19.1942      17.6867
170150......................................................      15.4283      15.5651      15.9072      15.6422
170151......................................................      13.3674      13.8934      14.3668      13.8637
170152......................................................      13.6846      14.9139      15.6423      14.7323
170160......................................................      13.3087      13.7108      14.4732      13.8369
170164......................................................      15.5597      16.6542      17.4072      16.5279
170166......................................................      17.5681      27.5567      12.7507      18.3396
170171......................................................      13.8059      12.5200      13.1792      13.1761
170175......................................................      17.8802      19.0232      20.1907      18.9985
170176......................................................      20.3194      21.3400      23.5043      21.7098
170180......................................................            *      16.6921       8.6352      11.8552
170182......................................................      14.1971      22.2164      21.3454      19.8791
170183......................................................      19.0919      20.3505      19.5182      19.7036
170184......................................................      27.0152            *            *      27.0152
180001......................................................      19.5188      17.9906      20.4885      19.3882
180002......................................................      18.1348      17.9669      17.5798      17.8819
180004......................................................      15.9921      17.2581      17.7149      16.9654
180005......................................................      20.6280      21.1390      22.4634      21.3796
180006......................................................      11.2254      11.4398      10.3400      11.0123
180007......................................................      17.1997      17.6776      17.9491      17.6005
180009......................................................      20.8103      21.4730      21.0608      21.1163
180010......................................................      17.5452      19.1100      19.6311      18.7406
180011......................................................      16.9311      17.1050      19.0526      17.8588
180012......................................................      18.7350      18.7223      19.0646      18.8428
180013......................................................      17.4487      18.2354      19.7418      18.5305
180014......................................................      20.8033      21.4856      21.3361      21.1759
180016......................................................      18.8422      19.8892      21.1458      20.0187
180017......................................................      15.1699      15.4140      15.6583      15.4240
180018......................................................      18.9020      17.1692      15.4892      17.0584
180019......................................................      16.7648      17.3970      17.8285      17.3565
180020......................................................      17.7782      17.7288      18.0111      17.8397
180021......................................................      15.1627      15.4580      17.0618      15.8957
180023......................................................      15.2219      15.8803      17.4717      16.1885
180024......................................................      15.3299      16.1731      16.5040      15.9951
180025......................................................      17.1688      14.1841      15.4180      15.4826
180026......................................................      14.1571      14.6804      15.0118      14.6082
180027......................................................      14.8869      16.4116      17.5286      16.2087
180028......................................................      19.3519      19.5276      15.7005      18.0068
180029......................................................      18.0191      17.7729      17.7248      17.8352
180030......................................................      17.0234      17.3430      17.9543      17.4342
180031......................................................      13.7862      13.9844      13.1848      13.6178
180032......................................................      16.0941      16.8318      17.2784      16.7976
180033......................................................      13.7667      17.7344      15.4131      15.5472
180034......................................................      17.3158      15.3369      16.3991      16.3000
180035......................................................      19.4485      20.1305      21.3666      20.2870
180036......................................................      19.1922      19.8398      20.1860      19.7448
180037......................................................      18.8053      19.9737      21.2184      19.9797
180038......................................................      17.1643      17.7626      18.5923      17.8512
180040......................................................      19.4450      19.5337      21.2229      20.0583
180041......................................................      15.1703      15.0785      16.3699      15.5655
180042......................................................      16.2924      16.7691      17.1519      16.7450
180043......................................................      16.6077      16.8027      14.6526      15.9643
180044......................................................      17.8196      18.5571      19.4984      18.6534
180045......................................................      17.7272      17.7130      20.8455      18.9499
180046......................................................      17.9096      19.2523      21.2080      19.4569
180047......................................................      15.0354      16.2304      18.6938      16.6027
180048......................................................      19.5681      18.3442      17.7816      18.5208
180049......................................................      16.0799      16.4319      16.5459      16.3594
180050......................................................      18.4753      17.8540      17.1493      17.7884
180051......................................................      15.6796      16.3960      17.5441      16.5170
180053......................................................      14.6299      15.9284      15.8994      15.5002
180054......................................................      16.3875      19.4858      20.0946      18.5771
180055......................................................      14.6446      15.2663      15.8422      15.2446

[[Page 39984]]

 
180056......................................................      16.6240      17.0056      17.5881      17.0744
180058......................................................      14.3562      15.9685      14.5355      14.9226
180059......................................................      14.2605      13.3955      14.7032      14.1102
180060......................................................       7.2139            *            *       7.2139
180063......................................................      11.9120      13.1036      12.4448      12.4785
180064......................................................      14.4872      15.2424      15.5066      15.0871
180065......................................................      20.0286      12.0629      11.1934      13.8815
180066......................................................      18.5635      19.2981      19.8956      19.2578
180067......................................................      18.5288      20.6322      20.1712      19.7577
180069......................................................      17.2956      17.7911      16.2916      17.1149
180070......................................................      13.8370      13.1923      15.9362      14.2840
180072......................................................      17.8554      16.9021      17.2347      17.3229
180075......................................................      15.0701            *            *      15.0701
180078......................................................      19.1615      21.1170      21.7116      20.6787
180079......................................................      13.4072      15.1636      15.9048      14.8197
180080......................................................      15.8327      16.4989      16.6428      16.3363
180087......................................................      14.9660      14.9167      15.6089      15.1555
180088......................................................      22.5349      22.0374      22.1774      22.2484
180092......................................................      16.3099      18.2405      18.3597      17.6633
180093......................................................      16.8286      17.0132      17.8492      17.2232
180094......................................................      12.5074      13.5490      13.6233      13.2263
180095......................................................      13.3991      13.8021      13.9050      13.6989
180099......................................................      13.6988      13.3631      13.2991      13.4593
180101......................................................      19.5644      18.4883            *      18.9778
180102......................................................      17.8751      17.9618      18.5240      18.1008
180103......................................................      19.2182      19.8965      20.3490      19.8359
180104......................................................      18.8730      18.9281      19.3922      19.0643
180105......................................................      14.0811      15.2394      16.6997      15.2994
180106......................................................      13.6062      14.3505      15.2895      14.3903
180108......................................................      14.6222      14.8187      14.4740      14.6381
180115......................................................      17.1079      16.7003      16.9096      16.9026
180116......................................................      16.9389      18.0392      18.6077      17.8709
180117......................................................      18.3821      17.7857      23.0192      19.6584
180118......................................................      12.1533      15.8597      16.9250      14.8270
180120......................................................      17.8145      16.1591      15.3115      16.3371
180121......................................................      14.5134      15.0983      20.0494      16.3330
180122......................................................      16.9678      18.5094      18.1930      17.8754
180123......................................................      18.9995      21.0613      21.1067      20.4023
180124......................................................      18.4064      17.4994      18.8487      18.2269
180125......................................................      19.7341      19.6416      14.9314      17.5744
180126......................................................      12.3959      12.9228      14.3551      13.2733
180127......................................................      17.3452      19.2581      17.6365      18.0663
180128......................................................      17.0508      17.6385      18.2817      17.6802
180129......................................................      17.8600      16.8378      22.3536      18.8696
180130......................................................      19.0110      19.8192      20.6450      19.8370
180132......................................................      17.2657      17.7744      19.5884      18.2006
180133......................................................      22.2325      21.6794      21.7800      21.8995
180134......................................................      13.6287      13.1935      14.5387      13.7967
180136......................................................      17.7146      17.3542            *      17.5359
180138......................................................      18.6149      19.3692      20.2102      19.4170
180139......................................................      18.7679      18.7198      20.5350      19.3756
180140......................................................      20.3953      16.8152      15.2719      17.3915
180141......................................................      20.0075      20.9820      23.8930      21.4590
180142......................................................            *            *      20.7510      20.7510
190001......................................................      17.0159      17.6832      18.1514      17.6263
190002......................................................      18.8381      19.1924      19.8834      19.2931
190003......................................................      22.1543      19.7749      19.9121      20.4811
190004......................................................      17.5385      17.7710      18.3620      17.8959
190005......................................................      16.7149      17.2422      17.5161      17.1568
190006......................................................      17.7335      17.8036      17.5911      17.7112
190007......................................................      13.6014      13.8189      14.4720      13.9833
190008......................................................      16.8916      18.6664      19.2456      18.2327
190009......................................................      14.2085      15.3555      15.9731      15.1819

[[Page 39985]]

 
190010......................................................      17.0192      16.2805      16.5020      16.6088
190011......................................................      15.1715      15.9534      15.6351      15.5881
190013......................................................      16.5706      16.8181      15.5019      16.2739
190014......................................................      17.0170      17.0959      17.8015      17.3107
190015......................................................      18.1943      18.6266      18.9896      18.6153
190017......................................................      15.7894      16.2393      17.5381      16.5250
190018......................................................      16.9761      15.0668      11.1898      14.5841
190019......................................................      17.4006      18.5257      18.3788      18.1281
190020......................................................      17.3084      17.5256      17.6840      17.5059
190025......................................................      16.0738      18.6369      16.8686      17.2271
190026......................................................      17.2166      18.1622      18.5015      17.9532
190027......................................................      16.1856      17.0827      17.4761      16.9034
190029......................................................      17.1103      16.5239      19.1967      17.5497
190033......................................................      10.7448            *            *      10.7448
190034......................................................      16.5066      16.8503      18.0754      17.1513
190036......................................................      19.9456      20.1780      20.0300      20.0491
190037......................................................      12.0237      17.6945      19.9878      16.0686
190039......................................................      17.1687      19.4713      19.0376      18.5119
190040......................................................      20.3180      21.4634      21.7376      21.1907
190041......................................................      17.8975      17.6646      17.9535      17.8382
190043......................................................      12.5660      15.5580      15.5618      14.5094
190044......................................................      17.1984      17.2892      17.4471      17.3108
190045......................................................      21.6948      21.6107      21.2853      21.5139
190046......................................................      19.3538      19.7964      20.4458      19.8736
190048......................................................      16.3404      16.6683      16.8136      16.6153
190049......................................................      16.4250      17.2280      17.7417      17.1570
190050......................................................      15.3771      16.1980      16.2854      15.9545
190053......................................................      12.4980      13.2159      13.0080      12.9160
190054......................................................      16.4683      19.1738      18.9059      18.1924
190059......................................................      15.8443      15.6942      15.8373      15.7915
190060......................................................      18.3689      14.7186      17.8443      16.7639
190064......................................................      19.9047      20.4482      18.2466      19.4909
190065......................................................      19.3856      20.9927      18.3091      19.5174
190071......................................................      13.5908      14.4827      16.4138      14.8320
190077......................................................      12.8290      15.7805      16.5536      15.0793
190078......................................................      13.4990      14.8826      16.9383      14.8793
190079......................................................      17.2909      17.7120      17.9403      17.6368
190081......................................................      12.0190      15.3198      14.9707      14.2301
190083......................................................      16.1374      18.8895      18.4951      17.8399
190086......................................................      14.9295      15.8694      16.5074      15.7738
190088......................................................      19.6328      20.5531      19.9362      20.0391
190089......................................................      12.7879      13.0503      15.0395      13.5823
190090......................................................      16.5580      16.6664      16.2351      16.4928
190092......................................................      18.0655            *            *      18.0655
190095......................................................      15.7316      16.2287      17.3258      16.3915
190098......................................................      19.2175      20.4897      21.0847      20.2301
190099......................................................      18.9255      19.9018      19.0635      19.3257
190102......................................................      19.0477      20.0300      20.7870      19.9631
190103......................................................      15.5698      12.1389      14.4158      13.8580
190106......................................................      17.7468      18.5813      18.5908      18.3281
190109......................................................      14.5288      15.5767      15.8187      15.3068
190110......................................................      12.9925      15.8052      15.7313      14.8387
190111......................................................      20.0376      19.7514      20.6508      20.1574
190112......................................................      19.2067      21.0232      22.0741      20.6951
190113......................................................      18.9922      12.5777            *      15.7380
190114......................................................      12.9083      12.6366      13.9209      13.1568
190115......................................................      20.4914      20.2473      22.7583      21.1252
190116......................................................      12.5881      15.5481      17.3757      15.1678
190118......................................................      12.9537      14.7876      16.3776      14.7222
190120......................................................      13.6938      13.9591      17.2309      14.9846
190122......................................................      14.8255      15.4793      15.3742      15.2287
190124......................................................      22.3825      20.6222      20.1206      20.9375
190125......................................................      18.6287      20.4517      19.8298      19.6458

[[Page 39986]]

 
190128......................................................      19.7127      20.4688      20.8770      20.3583
190130......................................................      12.4307      15.1467      14.0379      13.8956
190131......................................................      19.5984      20.7565      18.8958      19.7536
190133......................................................      13.4750      13.5383      15.1393      13.9917
190134......................................................      12.6774      12.1749      12.4507      12.4351
190135......................................................      21.3511      21.6875      21.3454      21.4650
190136......................................................      11.3250      12.4091      15.1662      13.0730
190138......................................................      22.7088            *            *      22.7088
190140......................................................      12.0285      14.2256      14.6829      13.6611
190142......................................................      14.9820      15.4861      16.2280      15.5517
190144......................................................      16.8360      16.2068      18.4405      17.1561
190145......................................................      13.9893      15.2345      16.2505      15.1638
190146......................................................      20.0941      21.2825      21.9607      21.1552
190147......................................................      14.3219      14.4345      14.7202      14.4910
190148......................................................      14.0180      16.6337      15.5338      15.4604
190149......................................................      15.1862      17.5997      16.4722      16.4169
190151......................................................      11.9190      14.7333      15.5210      14.0028
190152......................................................      20.3951      22.2070      22.0319      21.4716
190155......................................................      11.0800            *            *      11.0800
190156......................................................      12.4786      15.7478      16.0442      14.6766
190158......................................................      19.6164      20.4637      20.4078      20.1474
190160......................................................      18.4746      17.1003      18.4662      18.0078
190161......................................................      14.6295      15.5737      15.9280      15.3544
190162......................................................      19.5027      20.6143      20.1962      20.0440
190164......................................................      16.3328      15.1783      18.2379      16.4778
190167......................................................      16.2880      16.6681      17.7611      16.9143
190170......................................................      13.5772      14.1750      14.5222      14.0895
190173......................................................      19.6362      23.6398      23.0934      22.0602
190175......................................................      20.6908      19.3625      20.4580      20.1298
190176......................................................      18.8205      24.0574      22.2316      21.4596
190177......................................................      20.3177      18.6715      19.7794      19.5846
190178......................................................      10.4941      11.0657      12.0372      11.1714
190182......................................................      20.0267      20.2855      20.7102      20.3281
190183......................................................      16.1064      16.7671      16.0752      16.3134
190184......................................................      14.8645      17.2044      19.8436      17.2547
190185......................................................      19.3707      20.1444      20.5852      20.0405
190186......................................................      16.3586      18.7568      17.4078      17.5306
190189......................................................      26.5419            *            *      26.5419
190190......................................................      18.6656      17.4642      15.8985      17.1134
190191......................................................      18.1353      20.4975      19.6911      19.4475
190196......................................................      14.8699      17.9225      18.6138      17.2784
190197......................................................      17.9166      19.5569      20.2082      19.2721
190199......................................................      13.4222      16.0637      15.3522      14.6078
190200......................................................      19.4148      22.0391      21.6852      21.0397
190201......................................................      19.1432      18.7079      19.7421      19.2055
190202......................................................      17.8959            *            *      17.8959
190203......................................................      21.3096      21.7350      21.7931      21.5975
190204......................................................      21.2119      21.4624      20.5784      21.0754
190205......................................................      18.1007      19.6587      19.3737      19.0483
190206......................................................      20.0648      21.7012      21.3307      21.0222
190207......................................................      17.6712      20.5082      19.0216      19.1034
190208......................................................      14.6096      20.0065      16.9641      17.1855
190218......................................................      18.1627      19.7518      19.2992      19.0335
190223......................................................      19.2550            *            *      19.2550
190227......................................................      12.1086            *            *      12.1086
190231......................................................      16.8850      15.8287      17.7247      16.7665
190235......................................................      18.2702            *            *      18.2702
190236......................................................      22.1837      19.3395      21.1982      20.9440
190238......................................................            *            *      20.6799      20.6799
190239......................................................            *            *      19.7601      19.7601
190240......................................................            *            *      14.3579      14.3579
200001......................................................      17.4890      18.0527      18.2513      17.9448
200002......................................................      18.7745      19.3629      22.3035      20.2028

[[Page 39987]]

 
200003......................................................      16.7389      16.9566      18.4141      17.3782
200006......................................................      19.7984      17.6586      21.0922      19.4856
200007......................................................      17.8859      18.7992      18.1681      18.2871
200008......................................................      20.5020      21.7489      21.5556      21.2780
200009......................................................      20.6433      22.2280      21.4763      21.4574
200012......................................................      17.0130      18.3484      19.1047      18.1711
200013......................................................      16.4933      18.0566      17.9378      17.5422
200015......................................................      20.1117            *            *      20.1117
200016......................................................      17.6623      18.0866      17.1187      17.6192
200017......................................................      19.6462      17.2930            *      18.7598
200018......................................................      17.2422      18.5397      17.8675      17.8479
200019......................................................      18.6399      19.2348      19.9245      19.2946
200020......................................................      20.5967      22.4526      22.3355      21.8088
200021......................................................      19.4052      19.9133      20.7361      19.9988
200023......................................................      14.9164      16.1707      20.2063      16.7560
200024......................................................      18.6518      19.4329      20.8336      19.6454
200025......................................................      19.0659      20.2259      20.4165      19.9282
200026......................................................      17.2842      18.1194      17.9021      17.7766
200027......................................................      18.2775      18.5659      19.4220      18.7949
200028......................................................      16.9306      19.5708      18.8763      18.4290
200031......................................................      15.9043      16.2217      16.1641      16.1005
200032......................................................      17.9160      18.9315      19.4613      18.7411
200033......................................................      21.4031      21.8634      22.4685      21.9155
200034......................................................      19.2407      20.1519      20.4941      19.9680
200037......................................................      18.2419      18.6713      20.3015      19.1236
200038......................................................      19.2147      23.3851      21.2632      21.2824
200039......................................................      20.2901      19.8589      20.1508      20.0694
200040......................................................      19.2970      19.5503      18.9580      19.2627
200041......................................................      17.6559      19.3563      18.8131      18.6006
200043......................................................      16.5368      16.7224      19.4295      17.5199
200050......................................................      18.0805      20.1214      20.2014      19.5017
200051......................................................      19.5925      22.1525      22.0712      21.5149
200052......................................................      15.1216      17.2099      17.6271      16.6895
200055......................................................      17.1729      18.8422      18.5983      18.1835
200062......................................................      16.5139      17.2273      18.4279      17.3769
200063......................................................      19.6658      19.9331      21.2121      20.2562
200066......................................................      16.3431      17.0289      17.0570      16.8076
210001......................................................      18.7266      20.4841      18.6617      19.2372
210002......................................................      22.8448      19.9219      23.5132      22.2827
210003......................................................      25.3730      20.3446      26.0447      23.6583
210004......................................................      23.5884      24.2909      24.9760      24.2880
210005......................................................      19.6162      21.4929      21.3829      20.7876
210006......................................................      17.7721      18.9436      19.3682      18.7016
210007......................................................      21.5415      23.1007      23.8840      22.8043
210008......................................................      19.5006      21.1768      21.2895      20.6531
210009......................................................      21.8111      20.5447      20.7479      21.0282
210010......................................................      14.3783      18.7197      19.5908      17.3758
210011......................................................      21.2422      21.4862      21.4043      21.3727
210012......................................................      23.4317      20.7203      21.3977      21.7764
210013......................................................      18.8455      19.7288      19.4505      19.3405
210015......................................................      16.6898      16.1912      18.7448      17.2340
210016......................................................      22.1469      23.8739      26.5193      24.0991
210017......................................................      17.1747      18.8928      18.5079      18.1448
210018......................................................      21.4055      22.2135      22.8553      22.1574
210019......................................................      19.0899      19.3046      20.6025      19.6453
210022......................................................      21.8160      22.6389      24.5744      23.0098
210023......................................................      21.7988      23.1950      22.9989      22.6719
210024......................................................      19.5645      20.6011      24.4280      21.4080
210025......................................................      19.5704      19.5876      21.2769      20.0208
210026......................................................      11.6440      12.1348      13.8668      12.6171
210027......................................................      18.4862      17.6855      17.1060      17.7943
210028......................................................      18.8623      19.6408      19.4157      19.3091
210029......................................................      22.3876      21.2167      25.4939      23.0892

[[Page 39988]]

 
210030......................................................      21.0169      21.7403      20.9574      21.2261
210031......................................................      15.5873      16.2299            *      15.9014
210032......................................................      18.4983      17.7228      20.1955      18.7972
210033......................................................      19.9144      20.8053      23.7588      21.3886
210034......................................................      16.1216      15.7322      19.4144      17.1228
210035......................................................      20.6092      20.2731      20.8317      20.5720
210037......................................................      18.7361      18.3072      20.5528      19.2053
210038......................................................      23.2616      23.4971      24.9762      23.8679
210039......................................................      20.7291      19.9901      21.3559      20.7067
210040......................................................      25.0770      21.5014      23.4252      23.3184
210043......................................................      18.5891      19.6474      22.4000      20.0973
210044......................................................      22.2438      22.5781      23.0917      22.6329
210045......................................................       9.6862      11.6086      12.1467      11.1781
210048......................................................      22.3923      23.0537      24.6921      23.3434
210049......................................................      17.6697      19.0821      19.3022      18.6991
210051......................................................      20.7633      22.4335      23.6476      22.3235
210054......................................................      23.5122      22.3559      23.2730      23.0396
210055......................................................      20.1012      29.2539      26.5272      25.0062
210056......................................................      20.9445      19.2662      22.9593      21.0605
210057......................................................      22.5717      23.8289      26.0076      24.0668
210058......................................................      21.4976      22.0753      16.3191      20.0884
210059......................................................      23.1274      22.6766      25.6052      23.5899
210060......................................................            *            *      26.5846      26.5846
210061......................................................      20.0203      17.2240      16.1931      17.8181
220001......................................................      26.3207      21.9369      22.9064      22.9526
220002......................................................      22.5808      24.1285      16.3789      20.4063
220003......................................................      19.1383      16.9246      17.9319      17.9948
220004......................................................      20.0058            *            *      20.0058
220006......................................................      22.1228      22.3085      22.6337      22.3566
220008......................................................      21.8873      24.4691      22.0796      22.7689
220010......................................................      21.9226      21.8582      22.0067      21.9297
220011......................................................      28.5673      26.1827      29.5290      28.2047
220012......................................................      29.5051      32.0829      31.2303      30.9286
220015......................................................      21.7813      22.5773      23.1893      22.4843
220016......................................................      23.1440      23.3750      23.0951      23.2050
220017......................................................      25.2630      22.4605      25.1568      24.2781
220019......................................................      19.1264      19.5613      19.8551      19.5190
220020......................................................      19.9925      21.4152      22.4295      21.2738
220021......................................................      23.6313            *            *      23.6313
220023......................................................      18.7625      16.1885            *      18.0910
220024......................................................      21.5871      21.5363      21.9316      21.6947
220025......................................................      19.9398      20.7882      22.8593      21.1235
220028......................................................      22.0721      22.8036      21.0630      21.9530
220029......................................................      21.8711      23.1509      25.6560      23.4858
220030......................................................      14.5383      18.5441      18.7429      17.2580
220031......................................................      28.1584      30.2430      29.3091      29.1415
220033......................................................      20.4120      20.0695      20.3609      20.2712
220035......................................................      21.9974      21.6396      23.1892      22.2365
220036......................................................      24.1570      24.6470      24.4091      24.3977
220038......................................................      22.3494      22.6518      22.3162      22.4382
220041......................................................      23.1483      23.4720      27.5034      24.5999
220042......................................................      25.2852      25.0779      26.0473      25.4181
220046......................................................      22.4677      22.7068      23.3149      22.8459
220049......................................................      23.0283      26.0025      27.2689      25.4891
220050......................................................      20.8345      22.0144      22.5265      21.7871
220051......................................................      20.4765      21.1033      21.7357      21.0973
220052......................................................      23.1376      23.7650      23.5225      23.4708
220053......................................................      21.2679      19.1280            *      20.2813
220055......................................................      21.5706      21.3743            *      21.4727
220057......................................................      23.0010      25.3902      25.8064      24.6606
220058......................................................      20.1888      19.9369      26.8345      22.1915
220060......................................................      26.1753      28.0843      28.0794      27.4392
220062......................................................      20.0560      20.4685      20.2254      20.2505

[[Page 39989]]

 
220063......................................................      20.9547      20.3951      20.8079      20.7132
220064......................................................      22.1785      22.3260      22.7497      22.4060
220065......................................................      20.1974      20.1364      20.1424      20.1584
220066......................................................      20.4586      20.7826      23.4477      21.6604
220067......................................................      25.7414      26.4443      27.5405      26.5452
220068......................................................       6.4548            *            *       6.4548
220070......................................................      19.7678      19.7528      20.9128      20.1099
220071......................................................      24.6508      25.6184      27.4151      25.8715
220073......................................................      25.8680      25.6025      26.1328      25.8683
220074......................................................      24.0523      25.6390      24.3057      24.7411
220075......................................................      21.5418      22.8057      22.5329      22.2794
220076......................................................      24.7783      22.6668      23.2795      23.6106
220077......................................................      24.8019      25.2646      26.1545      25.3933
220079......................................................      21.0090      22.6256      22.0769      21.8560
220080......................................................      20.5007      21.5238      22.1971      21.3825
220081......................................................      25.3370      29.1726      29.6682      28.0686
220082......................................................      20.0175      21.6726      22.1453      21.2140
220083......................................................      23.0759      23.9156      22.5815      23.1732
220084......................................................      24.6624      23.6641      25.3761      24.5459
220086......................................................      30.4649      23.8705      26.7778      26.4452
220088......................................................      23.3783      22.9067      23.4258      23.2384
220089......................................................      21.7884      23.0965      25.4106      23.3099
220090......................................................      21.6353      22.0041      23.3049      22.2774
220092......................................................      17.0409      18.5239      24.7905      19.4783
220094......................................................      21.9853            *            *      21.9853
220095......................................................      21.4468      21.4831      21.7851      21.5735
220098......................................................      20.8596      21.5906      23.1547      21.8533
220100......................................................      25.3484      25.7077      27.5841      26.2007
220101......................................................      24.3260      25.9204      27.0711      25.7662
220104......................................................      27.5297      28.0021      28.7258      28.0695
220105......................................................      21.6873      21.4129      21.9185      21.6684
220106......................................................      24.5518      25.6577      25.9277      25.3659
220107......................................................      20.2719            *            *      20.2719
220108......................................................      22.6372      21.9115      23.4975      22.6709
220110......................................................      29.1927      28.7071      29.1648      29.0217
220111......................................................      23.0475      23.8066      24.7510      23.8707
220116......................................................      24.9744      26.1662      32.0049      27.4579
220118......................................................      30.5213            *            *      30.5213
220119......................................................      22.8586      23.3216      23.8785      23.3181
220123......................................................      27.3063      25.8994      32.4678      28.6276
220126......................................................      20.9557      22.5218      23.6045      22.3000
220128......................................................      20.5636            *            *      20.5636
220133......................................................      35.2747      25.4596      29.3911      30.0324
220135......................................................      25.0798      25.6522      28.3648      26.3313
220153......................................................      23.8981      22.9592            *      23.4152
220154......................................................      22.1261      22.4770      21.1563      22.0118
220163......................................................      27.3527      29.1143      29.2299      28.5578
220171......................................................      23.4340      24.5553      24.9261      24.3151
230001......................................................      19.2015      19.8020      20.0438      19.6841
230002......................................................      21.9058      22.7991      23.0439      22.5920
230003......................................................      19.6118      19.8420      21.2215      20.2501
230004......................................................      22.0310      23.1036      20.5005      21.8004
230005......................................................      19.4040      18.5644      17.0943      18.3438
230006......................................................      18.4681      19.1041      20.4978      19.3271
230007......................................................      19.4339      15.5538            *      18.1334
230012......................................................      18.6663      15.0803            *      16.5807
230013......................................................      20.6322      20.8018      22.2211      21.1847
230015......................................................      20.4264      20.1104      20.6464      20.3967
230017......................................................      20.3975      22.2822      22.9755      21.8495
230019......................................................      21.3222      22.2622      23.6674      22.4892
230020......................................................      21.3206      22.1280      21.8526      21.7774
230021......................................................      18.5670      18.9636      19.8256      19.1973
230022......................................................      19.7598      18.8006      21.9129      20.1618

[[Page 39990]]

 
230024......................................................      27.9551      23.7326      24.9664      25.4314
230027......................................................      18.0285      14.6950      19.6393      17.2624
230029......................................................      21.0636      19.4911      22.1782      20.9312
230030......................................................      17.7040      18.3916      18.6406      18.2548
230031......................................................      17.5352      19.3162      19.9465      18.8845
230032......................................................      20.6821      21.8845      24.8930      22.4347
230034......................................................      17.2302      19.0473      19.4366      18.6363
230035......................................................      17.5607      17.5109      17.7490      17.6051
230036......................................................      21.7565      23.2119      23.8398      22.9390
230037......................................................      19.0688      20.4747      23.2751      20.8659
230038......................................................      23.3876      23.5251      21.9692      22.9521
230040......................................................      20.3897      21.4393      20.7841      20.8605
230041......................................................      19.0278      20.3131      21.7364      20.3273
230042......................................................      19.4937      22.1043      21.3870      21.0005
230046......................................................      25.9482      25.5696      25.3206      25.6107
230047......................................................      20.6379      21.5381      22.3595      21.5205
230053......................................................      22.1781      25.4968      26.8917      24.7553
230054......................................................      19.5427      20.6963      20.8014      20.3482
230055......................................................      19.8381      20.7932      20.8492      20.4732
230056......................................................      16.4101      16.0766      17.8091      16.7213
230058......................................................      18.2349      20.4165      21.0303      19.9623
230059......................................................      19.5098      19.9240      20.7092      20.0517
230060......................................................      17.8716      19.8021      19.8987      19.1871
230062......................................................      16.2952      17.1540      18.8039      17.3634
230063......................................................      20.2211      20.4171            *      20.3143
230065......................................................      21.1507      22.3459      22.7416      22.2057
230066......................................................      21.5116      22.1768      23.0475      22.2618
230069......................................................      21.7909      23.2076      24.2470      23.0592
230070......................................................      20.0645      20.2505      21.5666      20.8098
230071......................................................      22.1556      22.9052      23.1337      22.7304
230072......................................................      20.4308      20.6944      20.4456      20.5245
230075......................................................      19.4316      20.0545      22.5866      20.6203
230076......................................................      23.8201      24.4547      24.7010      24.2886
230077......................................................      20.3937      21.0178      20.2823      20.5602
230078......................................................      16.2486      17.5577      17.9868      17.2435
230080......................................................      18.9084      19.7687      20.2104      19.6745
230081......................................................      17.9510      19.0345      19.0199      18.6644
230082......................................................      17.7417      18.2992      19.0419      18.3501
230085......................................................      17.5447      20.2096      23.4996      20.3924
230086......................................................      16.9754      18.9420      20.1730      18.6767
230087......................................................      15.7694      18.9034      19.9700      18.0112
230089......................................................      21.3914      23.9100      22.6994      22.6194
230092......................................................      18.9567      20.0145      20.7738      19.9304
230093......................................................      20.1928      20.4655      20.6314      20.4325
230095......................................................      16.7830      17.3313      17.6444      17.2565
230096......................................................      22.5613      22.8410      22.7785      22.7256
230097......................................................      20.0960      21.2854      21.1254      20.8481
230099......................................................      20.2529      21.1933      21.7513      21.0709
230100......................................................      13.1107      17.1336      17.3842      16.0298
230101......................................................      18.6098      20.0932      20.5315      19.7445
230103......................................................      19.6014      22.7696      11.3429      17.7532
230104......................................................      23.4703      23.1457      24.1238      23.5809
230105......................................................      20.8765      21.5210      22.6098      21.6727
230106......................................................      18.3508      20.7997      21.6825      20.2936
230107......................................................      14.6673      16.5966      17.1386      15.9949
230108......................................................      17.4231      18.8631      20.3437      18.8600
230110......................................................      17.8017      18.9825      19.7262      18.8384
230113......................................................      11.1676      14.9411            *      12.8926
230115......................................................      16.4728      18.4050      19.6281      18.1783
230116......................................................      16.3563      16.5419      14.5692      15.7763
230117......................................................      23.9389      25.9318      25.6797      25.1927
230118......................................................      21.7089      21.3028      20.6797      21.2068
230119......................................................      23.9568      21.1918      22.6555      22.5908

[[Page 39991]]

 
230120......................................................      19.6400      18.5264      20.3306      19.4421
230121......................................................      20.0786      20.3158      21.3342      20.5789
230122......................................................      18.0903      20.9078            *      19.5648
230124......................................................      18.8938      20.3608      18.9981      19.3961
230125......................................................      15.3497            *            *      15.3497
230128......................................................      23.5787      24.9081      24.0724      24.1436
230130......................................................      22.5204      23.5170      22.1775      22.7280
230132......................................................      26.1727      26.6386      26.1946      26.3381
230133......................................................      17.5688      17.6894      17.1058      17.4473
230134......................................................      15.3248            *            *      15.3248
230135......................................................      22.7401      22.5258      20.5637      22.0738
230137......................................................      18.3431      19.1813            *      18.7522
230141......................................................      23.0496      22.1299      22.4570      22.5592
230142......................................................      20.1242      22.2940      23.5621      21.8277
230143......................................................      16.4468      16.3043      16.7948      16.5112
230144......................................................      20.9906      22.1108      23.4237      22.1285
230145......................................................      16.5986      20.2542      19.2638      18.8354
230146......................................................      18.6293      20.5044      21.2260      20.1486
230147......................................................      20.5144      21.8496      23.2755      21.8616
230149......................................................      14.1740      20.7691      18.8005      17.7545
230151......................................................      20.8884      22.1713      23.3967      22.0865
230153......................................................      17.3280      19.5633      18.7403      18.5291
230154......................................................      14.5846      15.4456      15.4362      15.1635
230155......................................................      16.9857      17.2076      20.5409      18.1875
230156......................................................      23.6126      24.7587      25.6228      24.6740
230157......................................................      19.7197      20.3667      17.3571      19.2380
230159......................................................      18.8426      20.0749            *      19.3914
230162......................................................      17.7689      21.4636      21.7148      20.3064
230165......................................................      23.3147      23.0106      23.8881      23.4094
230167......................................................      20.3210      21.5048      22.9745      21.5685
230169......................................................      22.8606      23.0652      24.3874      23.4345
230171......................................................      14.9595      13.3863      17.1282      15.0778
230172......................................................      20.2191      20.6417      21.4675      20.7898
230174......................................................      20.8542      23.0272      22.7304      22.1820
230175......................................................      21.8097      16.8909            *      19.0428
230176......................................................      21.8618      22.7772      23.8204      22.8229
230178......................................................      16.0818      16.9156      17.3030      16.7485
230180......................................................      15.4837      15.8769      18.5744      16.6297
230184......................................................      17.2928      19.0604      19.7717      18.6605
230186......................................................            *      19.5337      15.7837      17.6806
230188......................................................      15.5563      15.7112      16.2975      15.8821
230189......................................................      15.9089      16.6838      17.9218      16.8493
230190......................................................      23.7134      26.8196      26.4687      25.7543
230191......................................................      17.1221      19.0013      18.4861      18.1647
230193......................................................      20.1805      19.7066      19.8287      19.9318
230195......................................................      22.3745      21.7775      22.9228      22.3732
230197......................................................      21.6184      24.0184      24.0854      23.1281
230199......................................................      18.4012      19.4451      20.6580      19.5586
230201......................................................      15.3206      17.2141      18.0787      16.9556
230204......................................................      22.9506      25.4181      23.4966      23.9387
230205......................................................      13.8861      14.3788      15.9314      14.6555
230207......................................................      20.3538      20.6375      21.2483      20.7256
230208......................................................      17.1501      16.0733      16.7454      16.6668
230211......................................................      17.5087      18.6744      21.8581      19.0214
230212......................................................      22.1370      23.3021      24.2611      23.2193
230213......................................................      15.3159      15.1908      15.5469      15.3407
230216......................................................      19.5921      20.3359      21.0710      20.3422
230217......................................................      20.9510      21.2707      22.2698      21.4978
230219......................................................      20.7018      19.1549      20.0442      19.9745
230221......................................................      21.5000            *            *      21.5000
230222......................................................      20.8430      22.1785      21.9711      21.6725
230223......................................................      21.4990      21.1528      22.6887      21.7715
230227......................................................      21.3801      23.7259      22.3155      22.4395

[[Page 39992]]

 
230230......................................................      22.5346      22.2385      22.3097      22.3587
230232......................................................      12.6373            *            *      12.6373
230235......................................................      15.9466      16.8684      17.7197      16.8275
230236......................................................      23.2178      24.3835      25.9676      24.5556
230239......................................................      19.2349      18.0942      17.8168      18.3625
230241......................................................      18.8451      19.1000      20.7297      19.5624
230244......................................................      21.0758      21.7413      22.2697      21.6892
230253......................................................      21.9497      20.5945      21.0433      21.1989
230254......................................................      21.2786      21.9402      22.6335      21.9383
230257......................................................      20.4721      19.6982      21.3880      20.5021
230259......................................................      21.1519      22.2393      22.3969      21.9147
230264......................................................      15.1818      17.1319      17.4864      16.5360
230269......................................................      22.8138      23.3105      24.0992      23.4229
230270......................................................      20.0803      22.6187      22.5985      21.6440
230273......................................................      23.4000      22.9199      22.8715      23.0744
230275......................................................      17.5975      17.7487      20.8985      18.2554
230276......................................................      18.5750      21.3722      25.8709      21.5415
230277......................................................      22.5012      23.1456      23.9771      23.2364
230278......................................................      16.6645      18.2110            *      17.3814
230279......................................................      16.0437      17.6973      17.8074      17.2147
230280......................................................      14.2249      15.6654      18.3497      15.8025
230283......................................................            *      27.9480      22.5082      24.9202
240001......................................................      22.8480      24.6207      25.6936      24.3586
240002......................................................      23.0240      22.7981      23.2307      23.0178
240004......................................................      23.9195      25.1908      24.4030      24.5010
240005......................................................      16.9775      17.9563      20.3193      18.3770
240006......................................................      27.1133      25.1602      23.0715      24.9568
240007......................................................      16.9802      17.7625      19.0850      17.9138
240008......................................................      21.8068      20.2158      23.3783      21.6628
240009......................................................      16.6910      16.8965      17.1187      16.9211
240010......................................................      23.6323      23.6477      25.4752      24.2587
240011......................................................      18.9559      20.5192      21.5875      20.3298
240013......................................................      18.9705      20.3282      21.7544      20.2656
240014......................................................      21.8560      23.0025      24.2610      23.0452
240016......................................................      19.8624      20.4017      22.2011      20.8274
240017......................................................      17.2325      18.3585      18.9272      18.1627
240018......................................................      19.0671      20.8501      18.4268      19.4219
240019......................................................      20.9869      22.1501      23.1477      22.1062
240020......................................................      19.5727      21.1937      20.8849      20.5389
240021......................................................      17.3968      18.7515      20.1457      18.6569
240022......................................................      19.1554      21.7889      21.3234      20.7594
240023......................................................      20.3923      21.5087      22.8224      21.4999
240025......................................................      17.2464      18.8345      20.0308      18.7384
240027......................................................      16.2531      19.1017      16.7758      17.3367
240028......................................................      19.3781      19.7918      25.1934      21.5071
240029......................................................      17.9880      21.1329      20.0164      19.6781
240030......................................................      18.4358      18.8547      20.1653      19.1669
240031......................................................      18.0652      18.1566      19.3983      18.5009
240036......................................................      20.3270      22.2460      22.1721      21.6421
240037......................................................      18.4564      19.2345      20.1195      19.3188
240038......................................................      26.3539      25.3061      24.3957      25.3169
240040......................................................      19.9022      20.4813      23.1352      21.0482
240041......................................................      19.2127      19.2864      21.8655      20.0389
240043......................................................      17.3064      17.7335      16.9859      17.3013
240044......................................................      18.9217      18.8411      20.3339      19.3394
240045......................................................      20.9873      21.1396      24.1557      22.0716
240047......................................................      21.8576      22.6152      23.8098      22.7467
240048......................................................      23.3110            *            *      23.3110
240049......................................................      22.1345            *            *      22.1345
240050......................................................      24.5027      25.2983      21.6499      22.6550
240051......................................................      18.2287      19.9195      22.5855      20.1307
240052......................................................      19.2190      20.7749            *      19.9948
240053......................................................      21.1987      22.9611      23.8693      22.7802

[[Page 39993]]

 
240056......................................................      22.2927      23.4226      23.7139      23.1375
240057......................................................      23.2377      24.2159      24.8686      24.1392
240058......................................................      14.9141      14.9697      18.4009      15.9713
240059......................................................      21.9575      23.6215      23.7808      23.1092
240061......................................................      25.5581      27.2603      25.9951      26.2655
240063......................................................      23.5426      23.7866      24.4031      23.9101
240064......................................................      20.7602      23.2860      22.8578      22.2645
240065......................................................      12.5547      12.7867      14.8734      13.4307
240066......................................................      22.0542      23.0698      24.1143      23.1023
240069......................................................      19.1834      19.8282      21.7991      20.2573
240071......................................................      19.1913      20.2101      21.2463      20.2337
240072......................................................      18.0015      21.1824      20.9529      20.0007
240073......................................................      15.6318      16.0840      17.3559      16.3592
240075......................................................      21.1934      21.2654      21.3357      21.2661
240076......................................................      21.0702      21.8795      22.3280      21.7859
240077......................................................      14.9493      15.3794      20.3445      16.8827
240078......................................................      22.7122      23.9150      25.1082      23.9382
240079......................................................      17.8206      18.4338      18.8345      18.3648
240080......................................................      23.7286      24.3399      25.5619      24.7160
240082......................................................      18.0272      18.3555      18.7995      18.3952
240083......................................................      19.2922      19.7637      21.0317      20.0094
240084......................................................      19.6078      19.4739      21.7421      20.2965
240085......................................................      18.0214      22.5736      20.9778      20.5540
240086......................................................      15.3302      16.9392      18.1401      16.9654
240087......................................................      17.0624      18.8352      21.3323      19.0315
240088......................................................      21.0202      21.6858      23.1056      21.8928
240089......................................................      18.4171      20.7239      21.1989      20.0227
240090......................................................      18.0490      19.2968      19.2166      18.8331
240093......................................................      18.6788      18.7092      20.2400      19.2268
240094......................................................      20.5705      20.9446      22.0247      21.2053
240096......................................................      18.3365      20.1644      21.0417      19.7961
240097......................................................      23.6230      24.2662      27.9496      25.1295
240098......................................................      20.6036      21.3467      24.2296      22.0643
240099......................................................      14.3759      14.4649      15.4964      14.7485
240100......................................................      19.1921      20.8302      20.8325      20.3051
240101......................................................      17.7478      19.2120      19.9837      18.9205
240102......................................................      15.5644      14.6067      16.3659      15.5008
240103......................................................      16.8805      19.1540      18.7510      18.2532
240104......................................................      24.0175      23.2178      23.5351      23.5902
240105......................................................      14.7904      14.3965            *      14.6094
240106......................................................      23.7818      23.5148      23.5005      23.6022
240107......................................................      19.0299      20.3983      20.9004      20.0558
240108......................................................      16.4605      15.3547      18.2427      16.5529
240109......................................................      13.1537      13.5537      16.3216      14.2359
240110......................................................      17.2834      19.4828      21.0277      19.2199
240111......................................................      17.0408      17.2100      17.8617      17.3567
240112......................................................      15.3246      15.8350      16.6244      15.9308
240114......................................................      15.4919      16.2505      17.3682      16.3794
240115......................................................      22.1575      23.7765      23.8675      23.3187
240116......................................................      15.1757      16.6731      18.3520      16.6014
240117......................................................      17.5676      18.0636      17.9941      17.8845
240119......................................................      22.4981      20.6126      21.8289      21.5894
240121......................................................      21.3747      23.4018      22.2266      22.3266
240122......................................................      18.0396      19.1811      21.2876      19.5090
240123......................................................      15.5968      16.5098      18.3941      16.7420
240124......................................................      19.0505      19.4400      20.4728      19.6473
240125......................................................      13.1505      12.3627      14.9708      13.5694
240127......................................................      14.7670      15.8966      17.9724      16.1476
240128......................................................      16.0759      17.2513      16.3608      16.5520
240129......................................................      15.4226      14.4212      16.5209      15.4258
240130......................................................      15.6477      14.9399      16.4271      15.6650
240132......................................................      24.4998      23.0669      23.1452      23.5239
240133......................................................      18.5216      19.2126      19.5293      19.1081

[[Page 39994]]

 
240135......................................................      13.6014      14.3069      15.7015      14.4270
240137......................................................      19.1770      20.3750      21.5073      20.3195
240138......................................................      13.7359      15.2062      16.7332      15.1922
240139......................................................      17.0163      20.8053      20.5496      19.6213
240141......................................................      21.9909      23.8066      23.1009      22.9648
240142......................................................      20.6139      25.2770      29.2238      24.5024
240143......................................................      14.2790      16.6172      20.4266      16.9078
240144......................................................      15.8710      18.2604      21.4469      18.2664
240145......................................................      14.9997      17.2778      19.0689      17.4197
240146......................................................      16.7496      16.0652      16.5412      16.4544
240148......................................................      11.3388      18.8779      19.5204      16.6060
240150......................................................      12.8255      13.8786      20.8331      15.4453
240152......................................................      20.2020      21.1678      22.4744      21.2973
240153......................................................      15.6079      16.5412      19.3336      17.0363
240154......................................................      17.0625      17.5769      21.5052      18.6158
240155......................................................      20.4189      19.8762      20.9385      20.4180
240157......................................................      14.6914      17.4168      13.7309      15.3007
240160......................................................      16.6034      15.9492      15.9014      16.1454
240161......................................................      15.4160      15.7996      16.8809      15.9681
240162......................................................      19.0404      16.6292      19.1542      18.1964
240163......................................................      17.8714      18.8320      20.4760      18.9698
240166......................................................      16.3907      17.3233      19.4131      17.7688
240169......................................................      18.6155      16.6725      16.3958      17.2174
240170......................................................      17.6501      18.8762      20.3779      18.9004
240171......................................................      16.7237      17.2886      18.5172      17.5402
240172......................................................      16.0711      18.2852      20.8606      18.2323
240173......................................................      16.7411      17.2655      18.5187      17.5027
240179......................................................      16.6464      17.5116      20.4004      18.1225
240184......................................................      14.3996      15.3793      16.8917      15.4746
240187......................................................      17.5154      19.9230      21.2736      19.5789
240193......................................................      16.3004      17.8226      18.4664      17.4827
240196......................................................      23.2666      24.3472      25.3479      24.3358
240200......................................................      14.7295      14.3415      14.9076      14.6539
240207......................................................      23.3339      24.1127      25.2814      24.2879
240210......................................................      23.8391      24.2218      24.5664      24.2274
240211......................................................      20.5548      19.7399      30.6260      22.1746
250001......................................................      18.1407      18.4233      19.2756      18.6319
250002......................................................      15.6036      17.2501      18.6938      17.1218
250003......................................................      15.6560      17.6539      16.7570      16.6622
250004......................................................      17.1177      17.8868      18.3860      17.7913
250005......................................................      12.0032      12.5993      12.5834      12.3909
250006......................................................      15.7036      16.9048      17.5192      16.6995
250007......................................................      19.1555      19.2913      19.7562      19.3984
250008......................................................      13.3179      14.1760      15.8506      14.4224
250009......................................................      16.1847      18.5610      17.7283      17.5396
250010......................................................      13.3372      13.3905      14.6101      13.7324
250012......................................................      18.4756      14.1623      16.7579      16.4800
250015......................................................      11.0747      13.5274      11.7249      11.9737
250017......................................................      17.3006      17.9410      20.5976      18.5334
250018......................................................      13.4707      11.9311      13.1687      12.7895
250019......................................................      17.1501      16.7425      18.0956      17.3536
250020......................................................      14.0618      13.4476      16.2698      14.4562
250021......................................................       9.0772       9.4318      10.5844       9.6552
250023......................................................      13.5440      13.9116      12.3434      13.2963
250024......................................................      11.5940      12.7127      12.9899      12.4525
250025......................................................      17.8890      19.0390      20.3625      19.2022
250027......................................................      12.4241      14.9519      14.5445      13.9032
250029......................................................      14.8456      16.4834      16.0682      15.8412
250030......................................................      13.6277      17.3636      26.6173      19.2750
250031......................................................      18.7663      17.9715      18.3825      18.3676
250032......................................................      17.2983      17.1339      17.5957      17.3467
250033......................................................      15.7646      17.8257      15.0941      16.2509
250034......................................................      18.1269      16.6988      17.0399      17.2230

[[Page 39995]]

 
250035......................................................      17.4148      15.2353      16.8349      16.3942
250036......................................................      13.7928      15.8445      16.1913      15.3676
250037......................................................      10.3212      15.4325      12.7156      12.4979
250038......................................................      13.6207      16.8454      17.7019      16.0182
250039......................................................      16.5105      14.1556      15.1409      15.2552
250040......................................................      15.6367      17.3430      18.3364      17.1495
250042......................................................      16.4728      16.3867      17.6531      16.8406
250043......................................................      13.6492      16.0729      16.6500      15.4718
250044......................................................      16.7462      16.1218      16.7321      16.5323
250045......................................................      19.4788      22.0839      21.8988      21.2480
250047......................................................      12.0953      13.3706      14.7461      13.3242
250048......................................................      15.7073      16.8932      17.6649      16.7793
250049......................................................      10.7578      11.6715      12.1635      11.5642
250050......................................................      13.9220      14.3949      15.1159      14.4819
250051......................................................       9.6017       9.3464      10.4900       9.8032
250057......................................................      14.2863      15.9237      16.1838      15.4582
250058......................................................      15.4206      15.5327      15.7197      15.5555
250059......................................................      14.2997      16.2845      16.6494      15.7755
250060......................................................       7.9882      13.0301      16.1804      11.2768
250061......................................................      13.9655      11.0308      11.5108      11.9846
250063......................................................      14.9743      13.2540      13.3092      13.7869
250065......................................................      12.6803      12.8853      13.6904      13.0682
250066......................................................      14.3274      15.6760      16.1742      15.4025
250067......................................................      15.2871      16.4120      16.8522      16.2039
250068......................................................      11.4272      13.6768      13.4127      12.8087
250069......................................................      15.7653      17.8960      16.8980      16.8834
250071......................................................      11.2079      14.3781      12.3488      12.5425
250072......................................................      16.9263      18.2218      18.9487      18.0776
250076......................................................            *      10.5098            *      10.5098
250077......................................................      11.4135      12.2564      13.7404      12.5026
250078......................................................      15.4571      15.6336      15.9739      15.6895
250079......................................................      19.0587      16.2712      16.5835      17.1998
250081......................................................      16.1412      17.3325      19.0358      17.4600
250082......................................................      14.0249      16.0975      17.1427      15.7611
250083......................................................       9.2019      14.2634      16.6065      13.1746
250084......................................................      19.7390      17.0189      20.6429      19.0165
250085......................................................      13.8487      14.3797      15.4477      14.5716
250088......................................................      16.7514      17.8674      18.2736      17.6409
250089......................................................      13.0481      13.4238      14.3027      13.5884
250093......................................................      15.0918      15.2044      16.1506      15.4926
250094......................................................      17.8539      18.0852      18.5063      18.1422
250095......................................................      16.3574      17.0039      17.4217      16.9079
250096......................................................      17.0713      19.0688      19.0584      18.3546
250097......................................................      18.4099      16.9905      15.5741      16.9320
250098......................................................      14.3017      13.1341      18.3874      15.0909
250099......................................................      14.4142      14.8528      15.1265      14.8018
250100......................................................      16.6033      17.1682      17.8688      17.2128
250101......................................................      16.3083      18.4685      17.7194      17.5079
250102......................................................      20.0190      23.9329      18.9348      20.8793
250104......................................................      17.5421      18.2502      18.7651      18.1832
250105......................................................      14.5986      14.5401      15.5133      14.8921
250107......................................................      13.6296      15.1496      15.0737      14.6455
250109......................................................      14.5496      22.1551      21.3867      18.8951
250112......................................................      14.2023      15.5610      16.3640      15.3179
250117......................................................      14.5171      16.1225      16.9787      15.9014
250119......................................................      12.7379      15.2199      16.1218      14.6728
250120......................................................      14.4126      15.3433      16.7182      15.4420
250122......................................................      17.7079      18.9417      19.2990      18.6619
250123......................................................      17.4068      18.8690      18.7863      18.3698
250124......................................................      12.6677      13.1823      13.2490      13.0310
250125......................................................      14.4867      20.8895      21.2660      18.4338
250126......................................................      14.7083      18.2355      21.9101      17.8900
250128......................................................      12.9968      14.0048      16.1418      14.4375

[[Page 39996]]

 
250131......................................................      10.2765      12.6056      12.4557      11.6657
250134......................................................      17.9755      17.0671      18.5142      17.8554
250136......................................................      18.0538      18.9689      21.3497      19.3579
250138......................................................      17.5999      18.4028      20.4550      18.6918
250141......................................................      17.1247      19.0113      19.6692      18.6505
250145......................................................      11.4047      10.2507      11.2120      10.9506
250146......................................................      13.2763      14.4924      14.7781      14.1955
250148......................................................      14.8234      18.0980      19.4233      17.4956
250149......................................................      12.9840      12.9569      15.2318      13.7102
250150......................................................            *            *      21.8599      21.8599
260001......................................................      17.5520      18.0971      20.1560      18.5941
260002......................................................      20.5878      22.1183      21.6597      21.4585
260003......................................................      14.3537      14.6553      15.4482      14.8108
260004......................................................      13.7528      13.0133      13.7035      13.4793
260005......................................................      19.7058      19.5554      23.9681      21.0036
260006......................................................      18.9408      19.7467      20.0994      19.6144
260008......................................................      16.2451      13.8495      16.8893      15.5719
260009......................................................      17.9364      18.5080      18.2863      18.2469
260011......................................................      18.3378      19.1027      19.5059      18.9819
260012......................................................      14.4594      14.3645      17.1662      15.3316
260013......................................................      15.5388      15.9884      16.1825      15.8932
260015......................................................      21.3327      16.5822      17.8817      18.4578
260017......................................................      15.8013      16.7916      16.9914      16.5434
260018......................................................      12.2293      12.0060      12.5301      12.2688
260019......................................................      23.6727      18.6113            *      20.6992
260020......................................................      21.8585      20.5142      20.2241      20.8205
260021......................................................      17.5694      22.1017      21.6237      20.1803
260022......................................................      19.3454      17.2462      17.7772      17.8898
260023......................................................      15.8235      16.4705      17.8649      16.6827
260024......................................................      13.4737      15.2356      15.7815      14.8371
260025......................................................      14.9377      15.4935      17.0965      15.8836
260027......................................................      21.0084      21.2977      22.0362      21.4252
260029......................................................      17.4744      19.7484      21.1858      19.3784
260030......................................................      11.2434      12.5118      11.9215      11.8847
260031......................................................      18.3039      19.4921      19.7249      19.1438
260032......................................................      20.8097      20.1988      19.6728      20.2222
260034......................................................      17.8986      17.4233      20.4902      18.5746
260035......................................................      12.5886      13.1065      13.0071      12.9052
260036......................................................      18.3128      16.7430      18.8104      17.9282
260039......................................................      14.1980      14.1866      14.6644      14.3527
260040......................................................      15.3853      17.3099      18.0140      16.9033
260042......................................................      17.4459      18.7567      18.7514      18.2697
260044......................................................      17.1177      15.9927      15.9206      16.3491
260047......................................................      17.2768      19.0112      19.2247      18.5386
260048......................................................      21.4309      20.0885      21.0602      20.8622
260050......................................................      18.7366      15.6908      16.8520      17.0991
260052......................................................      17.7502      18.0553      18.0914      17.9657
260053......................................................      12.0098      15.2236      16.5166      14.4005
260054......................................................      17.3708      20.0199      20.6242      19.2873
260055......................................................      13.7961      12.0118      15.4214      13.6790
260057......................................................      15.3276      17.4636      19.7144      17.7259
260059......................................................      15.7887      16.1000      17.0546      16.3478
260061......................................................      15.0099      14.7175      15.7112      15.1405
260062......................................................      20.2655      20.1477      21.3138      20.5946
260063......................................................      16.8474      18.2309      18.8973      17.9893
260064......................................................      16.5033      16.5934      17.8033      16.9429
260065......................................................      18.4654      19.4382      20.0975      19.3238
260066......................................................      14.4163      14.9640      15.3460      14.8934
260067......................................................      12.1588      14.2249      15.1837      13.8617
260068......................................................      19.8261      20.2418      19.4240      19.8242
260070......................................................      21.6873            *      13.9510      17.3672
260073......................................................      13.0075      14.2550      15.9182      14.4333
260074......................................................      15.4480      19.0350      19.8915      18.1123

[[Page 39997]]

 
260077......................................................      18.2594      18.6473      19.4482      18.8035
260078......................................................      15.4754      15.6381      14.9463      15.3700
260079......................................................      14.8281      14.2985      16.1453      15.0169
260080......................................................      12.5631      13.5384      14.6832      13.5392
260081......................................................      18.9629      21.0151      20.3053      20.0653
260082......................................................      15.7880      15.9407      15.9858      15.9090
260085......................................................      19.5153      20.4669      20.7051      20.2110
260086......................................................      14.8730      14.3164      15.2927      14.8291
260091......................................................      19.6081      19.9987      21.5464      20.5925
260094......................................................      15.8705      18.0085      18.5395      17.5281
260095......................................................      19.7672      19.6944      20.7292      20.0618
260096......................................................      21.7176      23.0282      22.5972      22.4661
260097......................................................      15.7899      16.5582      19.0632      17.1704
260100......................................................      15.7324      15.7047      16.6523      16.0345
260102......................................................      16.3653      20.1264      20.6361      18.8983
260103......................................................      17.3541      18.5957      19.7146      18.4987
260104......................................................      19.1158      21.0138      20.3176      20.0928
260105......................................................      20.8006      24.7223      24.8181      23.3052
260107......................................................      18.4618      19.8422      20.4269      19.5069
260108......................................................      19.2422      19.4609      20.0034      19.5906
260109......................................................      13.4400      13.9129      14.8181      14.0725
260110......................................................      16.9952      17.8375      18.3227      17.7209
260113......................................................      14.8968      14.6756      16.2223      15.2316
260115......................................................      17.8971      19.2259      17.4698      18.2033
260116......................................................      14.5715      16.2774      14.9812      15.2548
260119......................................................      16.2000      16.8836      17.2942      16.7641
260120......................................................      17.1269      16.3755      16.4904      16.6414
260122......................................................      14.5390      14.9697      16.0931      15.2238
260123......................................................      13.9960      14.6444      14.6822      14.4496
260127......................................................      15.9481      18.3572      18.4026      17.5109
260128......................................................      11.2705      13.0481      12.6414      12.2813
260129......................................................      14.6353            *            *      14.6353
260131......................................................      19.7491      17.7686      18.4154      18.5978
260134......................................................      16.5834      16.2832      17.5127      16.7877
260137......................................................      15.2169      17.9531      19.4697      17.5188
260138......................................................      21.3885      22.6491      23.2364      22.4440
260141......................................................      17.9598      19.1580      19.1893      18.7555
260142......................................................      16.0299      17.1248      17.3084      16.7937
260143......................................................      11.9389      12.7867      13.9040      12.7859
260147......................................................      13.6568      14.0778      14.7769      14.1672
260148......................................................      10.3383      11.8674      11.3524      11.2072
260158......................................................      12.4020      12.3005      12.7699      12.4966
260159......................................................      18.2232      20.3177      19.7951      19.3893
260160......................................................      16.1922      15.8394      16.5792      16.2009
260162......................................................      20.7103      19.5655      21.4099      20.5728
260163......................................................      14.8051      16.4245      15.8593      15.6940
260164......................................................      14.3089      14.9372      15.1211      14.8191
260166......................................................      19.5343      20.1025      21.1224      20.2675
260172......................................................      12.4851      15.4163      16.0772      14.6285
260173......................................................      11.9777      12.8523      14.2090      13.1471
260175......................................................      16.2940      16.9023      17.5625      16.9246
260176......................................................      19.5449      26.8712      21.6044      22.7500
260177......................................................      20.7457      21.2578      21.9014      21.3180
260178......................................................      21.4080      19.6638      20.2796      20.4480
260179......................................................      20.7397      21.4906      22.7185      21.6624
260180......................................................      18.5398      19.5819      18.9881      19.0361
260183......................................................      20.1940      20.0712      21.3175      20.5306
260186......................................................      18.0588      19.3238      19.6026      19.0698
260188......................................................      18.5772      20.6388      22.5060      20.5016
260189......................................................      10.7518      11.3004      16.4233      12.7425
260190......................................................      18.1639      18.5168      19.3419      18.6978
260191......................................................      19.3386      17.9812      18.1604      18.4767
260193......................................................      20.5055      21.1588      20.2577      20.6284

[[Page 39998]]

 
260195......................................................      15.9518      17.7237      19.7068      17.8042
260197......................................................      16.4605      19.2840      20.5453      18.3884
260198......................................................      17.6381      11.9751      19.7552      15.6949
260200......................................................      18.8755      20.5339      20.6888      20.0233
260205......................................................            *      17.6210            *      17.6210
270002......................................................      17.1866      28.9959      19.2387      20.5385
270003......................................................      22.1299      22.0995      22.5019      22.2424
270004......................................................      21.3442      19.6292      19.4834      20.1660
270006......................................................      16.1872      16.0238      17.0715      16.3653
270007......................................................      13.1679      11.3143      13.8824      12.6774
270009......................................................      17.7016      17.2292      20.8238      18.5056
270011......................................................      19.8229      20.2669      21.1653      20.3748
270012......................................................      22.8770      19.7346      19.7878      20.8557
270013......................................................      20.4012            *            *      20.4012
270014......................................................      18.5595      19.0872      19.9859      19.2205
270016......................................................      19.7675      19.6717      18.6149      19.4350
270017......................................................      19.5798      21.0800      20.0152      20.2382
270019......................................................      12.7812      18.1099      15.4128      15.4635
270021......................................................      16.6541      17.1787      16.9457      16.9258
270023......................................................      20.3641      22.2639      22.7181      21.7139
270026......................................................      15.6381      17.5102      18.0568      17.0775
270027......................................................       9.7758      13.1392      17.2091      12.8885
270028......................................................      17.2132      21.1492      19.1177      19.1160
270029......................................................      17.8852      16.5666      17.3710      17.2639
270032......................................................      17.0285      17.7393      18.7811      17.8749
270033......................................................      16.4554      16.9602      18.4876      17.2764
270035......................................................      17.6482      16.8295      16.4302      16.9974
270036......................................................      14.0815      14.2537      16.8552      14.8821
270039......................................................      15.3501      15.9368      19.6796      16.7774
270040......................................................      19.1901      18.8145      20.1242      19.3585
270041......................................................      16.7791      19.0327      25.8153      19.7981
270044......................................................      13.4559      16.7710      17.5137      15.8620
270046......................................................      17.1048            *            *      17.1048
270048......................................................      15.8403      17.0154      18.0666      16.8972
270049......................................................      21.1670      22.2444      22.2540      21.8899
270050......................................................      18.0448      16.7110      19.9356      18.1546
270051......................................................      18.9468      20.2735      20.1950      19.8100
270052......................................................      14.8042      14.4773      14.7009      14.6552
270057......................................................      20.0080      21.1317      20.6714      20.6119
270058......................................................      14.0669      14.7481      16.1412      14.9510
270059......................................................      15.5957      14.7530      19.1808      16.3576
270060......................................................      14.0212      15.2727      20.4148      16.5316
270063......................................................      14.2287      12.6108      15.1049      13.8837
270073......................................................      15.5281      14.4569      16.1937      15.3359
270079......................................................      15.0277      15.6873      16.7048      15.7603
270080......................................................      14.0437      16.3171      15.0705      15.0926
270081......................................................      15.5207      15.6262      16.7389      15.9424
270082......................................................      16.1280      17.3443      23.1245      18.7794
270083......................................................      20.8231      18.4432      17.8554      18.9597
270084......................................................      16.2075      16.6243      16.2958      16.3734
280001......................................................      17.8928      17.3541      18.1831      17.7825
280003......................................................      21.9957      22.3179      23.0213      22.4564
280005......................................................      18.7477      19.2405      23.6949      20.6104
280009......................................................      18.7541      19.8145      20.9643      19.8453
280010......................................................      16.5417      17.4859      20.0462      17.5272
280011......................................................      13.9627      15.8573      15.9614      15.3328
280012......................................................      16.4079            *            *      16.4079
280013......................................................      22.1767      22.8063      22.5163      22.5039
280014......................................................      15.2414      15.9596      16.8368      15.9667
280015......................................................      14.6353      17.0281      16.6939      16.1405
280017......................................................      14.1897      14.2059      13.9939      14.1278
280018......................................................      14.8492      15.1328      15.4496      15.1512
280020......................................................      19.3963      19.9667      21.2467      20.2637

[[Page 39999]]

 
280021......................................................      16.6949      17.1048      17.6345      17.1389
280022......................................................      15.7059      16.7179      16.8184      16.3693
280023......................................................      21.2387      25.8494      22.3433      23.0540
280024......................................................      13.9115      14.2186      15.0380      14.3613
280025......................................................      14.2701      15.5850      21.4764      16.6875
280026......................................................      16.0599      16.6861      16.5851      16.4520
280028......................................................      15.8871      17.3176      18.0793      17.1201
280029......................................................      19.0519      23.1292      24.4359      21.9196
280030......................................................      28.7091      24.5366      24.7723      25.8891
280031......................................................      13.2242      13.5654       9.6321      12.1542
280032......................................................      19.3884      18.8964      19.1191      19.1301
280033......................................................      14.9334      15.7583      17.4745      16.1329
280034......................................................      15.2821            *            *      15.2821
280035......................................................      15.3304      15.9170      16.6872      15.8969
280037......................................................      16.1684      16.7952      17.1064      16.6926
280038......................................................      16.4685      17.0878      18.2503      17.2635
280039......................................................      15.1916      16.0442      16.1587      15.8239
280040......................................................      18.9717      19.5333      20.9896      19.8846
280041......................................................      13.3901      16.4083      16.5503      15.4920
280042......................................................      15.3029      16.1191      16.6239      16.0122
280043......................................................      15.7858      16.6570      17.5937      16.7160
280045......................................................      14.2741      16.9048      15.7630      15.6286
280046......................................................      13.7155      17.9221      17.3214      16.1724
280047......................................................      18.3743      18.3407      17.4735      18.0424
280048......................................................      14.0702      15.8723      15.8100      15.1939
280049......................................................      15.6343      18.3605      18.4365      17.4677
280050......................................................      15.3413      16.6432      20.0379      17.6064
280051......................................................      15.8504      15.6336      17.1942      16.1502
280052......................................................      13.6489      14.0819      14.1201      13.9629
280054......................................................      17.5819      18.7992      18.7575      18.3765
280055......................................................      12.9933      13.5667      13.8129      13.4587
280056......................................................      14.0151      12.6475      15.6135      14.0018
280057......................................................      15.7623      18.0454      20.0686      17.7576
280058......................................................      17.8798      19.6752      21.4868      19.6876
280060......................................................      28.6047      19.7527      20.7022      22.2434
280061......................................................      17.9511      17.1629      18.6370      17.9240
280062......................................................      13.6738      14.4896      15.6018      14.6170
280064......................................................      15.5092      16.2977      16.8330      16.2046
280065......................................................      18.5327      19.2932      20.7370      19.5513
280066......................................................      11.6416      11.6621      11.7207      11.6766
280068......................................................      10.1327       9.4943      10.5987      10.0463
280070......................................................      13.7353      17.7400      22.6201      17.5276
280073......................................................      17.0583      17.4244      17.7698      17.4266
280074......................................................      15.2182      16.4310      17.3143      16.2521
280075......................................................      13.7875      15.5327      13.2230      14.1041
280076......................................................      13.9203      14.8469      16.7488      15.0947
280077......................................................      19.0145      19.2068      20.0148      19.4096
280079......................................................       9.9132      10.4540      16.6117      11.4307
280080......................................................      14.3528      15.3308      16.9487      15.6285
280081......................................................      20.9196      21.0771      20.9606      20.9873
280082......................................................      13.1250      14.3399      14.6173      14.0723
280083......................................................      17.5544      18.2992      21.5336      19.2134
280084......................................................      11.6868      12.5836      13.6536      12.6157
280085......................................................      21.5793      20.4302      20.4825      20.9817
280088......................................................      22.1147      20.2961            *      21.2560
280089......................................................      17.4696      18.1668      18.9567      18.1923
280090......................................................      14.7191      14.1362      15.1274      14.6962
280091......................................................      15.2184      15.8436      16.1866      15.7538
280092......................................................      14.1998      14.1945      14.7912      14.4303
280094......................................................      15.8843      17.6873      16.3474      16.6450
280097......................................................      14.2990      14.1734      13.8223      14.0824
280098......................................................      10.1686      13.0029      12.5875      12.0141
280101......................................................      17.4168      13.5261      16.9973      15.7528

[[Page 40000]]

 
280102......................................................      12.9367      14.0102            *      13.4735
280104......................................................      13.3842      13.2819      16.2167      14.1456
280105......................................................      18.7851      18.6575      21.0735      19.5325
280106......................................................      15.5396      16.1247      16.0679      15.9189
280107......................................................      13.4553      13.3311      14.4679      13.7065
280108......................................................      17.2185      17.5625      17.1961      17.3277
280109......................................................      11.0622      12.6803      12.4408      12.0678
280110......................................................      12.2950      12.7546      14.2136      13.0914
280111......................................................      23.0856      21.8773      19.6283      21.4131
280114......................................................      13.5580      15.7160      17.3076      15.4628
280115......................................................      16.4282      16.7041      18.1480      17.1049
280117......................................................      16.8216      17.7276      18.8279      17.8057
280118......................................................      16.9228      16.8687      18.6524      17.4822
280123......................................................      20.7732      14.0637      11.8582      15.0281
280125......................................................            *      16.1332      16.3944      16.2644
290001......................................................      22.4188      22.8226      22.7450      22.6608
290002......................................................      20.9442      17.2554      16.5419      18.3712
290003......................................................      25.0066      22.8840      24.2175      23.9864
290005......................................................      17.8609      19.4888      21.9814      19.6686
290006......................................................      19.8815      21.8070      22.4063      21.4371
290007......................................................      29.6864      29.7706      30.9075      30.1389
290008......................................................      20.2506      20.6190      24.1255      21.5150
290009......................................................      22.7399      23.3620      23.9373      23.3345
290010......................................................      14.4800      15.6423      16.4476      15.5219
290011......................................................      16.4419      20.1564      21.1234      19.0261
290012......................................................      21.5139      21.8275      25.0430      22.8581
290013......................................................      17.0883      18.2713      15.7932      17.0224
290014......................................................      18.3755      18.9743      18.7829      18.7144
290015......................................................      17.8303      22.3487      19.4504      19.7229
290016......................................................      12.7869      14.3542      23.8656      16.2244
290019......................................................      20.9336      21.2509      22.2045      21.4895
290020......................................................      26.1502      20.8733      21.2380      22.7207
290021......................................................      21.1250      21.5806      22.9488      21.8726
290022......................................................      24.0856      24.5468      25.5011      24.7398
290027......................................................      16.4289      16.7786      13.3769      15.4098
290032......................................................      22.7882      22.8447      23.9504      23.1730
290036......................................................      18.6112            *      12.9074      15.9259
290038......................................................      23.1402      20.6753      27.7030      22.6435
290039......................................................      25.8004      25.3864      25.5024      25.5429
290041......................................................            *            *      25.9905      25.9905
290042......................................................            *            *      18.7527      18.7527
290043......................................................            *            *      27.9053      27.9053
300001......................................................      21.4192      22.0909      23.8567      22.4761
300003......................................................      23.3777      22.9111      24.1297      23.4634
300005......................................................      19.9876      20.7545      22.2858      20.9804
300006......................................................      18.9331      23.7793      18.9745      20.5179
300007......................................................      19.3447      20.2372      20.6325      20.0620
300008......................................................      16.4649      20.7702      19.6149      18.9666
300009......................................................      20.0057      18.0602      20.0938      19.3221
300010......................................................      19.3833      19.3940      20.2130      19.6671
300011......................................................      21.2429      22.4325      23.0279      22.1850
300012......................................................      23.8859      24.5673      24.5619      24.3251
300013......................................................      18.9664      19.1247      20.1669      19.4250
300014......................................................      19.7969      20.3292      20.1774      20.0987
300015......................................................      19.9308      20.4916      19.6627      20.0406
300016......................................................      18.5037      21.8659      17.8148      19.4173
300017......................................................      22.3408      21.6563      22.7191      22.2414
300018......................................................      20.8947      21.2381      21.6385      21.2565
300019......................................................      20.6090      20.9753      19.6728      20.4155
300020......................................................      21.9725      21.9165      22.6627      22.2032
300021......................................................      17.3477      18.6211      19.3101      18.4253
300022......................................................      17.1864      18.3507      19.1875      18.2148
300023......................................................      20.3909      22.1210      22.7649      21.7833

[[Page 40001]]

 
300024......................................................      17.9460      19.9116      21.5842      19.6334
300028......................................................      18.0515      17.4075      20.0778      18.5816
300029......................................................      20.8961      22.5748      22.6013      22.0065
300033......................................................      19.8506      17.1869      17.1632      17.9333
300034......................................................      23.5215      25.5182      24.4975      24.5048
310001......................................................      27.5967      28.1329      27.4730      27.7287
310002......................................................      27.8735      28.3434      27.9728      28.0592
310003......................................................      27.4152      29.1096      27.5624      28.0099
310005......................................................      23.0493      22.1146      22.9712      22.6992
310006......................................................      21.5557      21.5957      22.0894      21.7417
310008......................................................      24.9483      23.5084      24.7618      24.4065
310009......................................................      23.1906      23.6371      21.7094      22.8601
310010......................................................      21.1064      22.5682      23.1060      22.2131
310011......................................................      23.4038      23.1977      24.2885      23.6223
310012......................................................      26.3249      26.5242      26.6772      26.5118
310013......................................................      22.1062      21.2251      22.5603      21.9726
310014......................................................      28.6964      27.4614      23.1956      26.3647
310015......................................................      26.7584      27.4331      27.9684      27.3934
310016......................................................      26.0518      24.3838      24.5206      24.9705
310017......................................................      26.0703      25.7902      24.5976      25.5018
310018......................................................      24.5312      22.8428      22.4779      23.3087
310019......................................................      23.0888      24.0542      24.9914      24.0619
310020......................................................      19.2663      24.1848      24.4152      22.3484
310021......................................................      22.6456      23.9369      25.4393      23.9309
310022......................................................      20.7276      21.2706      20.8258      20.9386
310024......................................................      22.7831      24.2353      24.9521      23.9428
310025......................................................      22.8129      24.3513      24.1812      23.7695
310026......................................................      23.8726      23.5491      22.1997      23.2228
310027......................................................      21.7666      21.8846      22.5696      22.0722
310028......................................................      23.5188      23.4577      23.9428      23.6444
310029......................................................      23.3801      22.6629      23.6610      23.2308
310031......................................................      25.1780      26.1567      26.6831      25.9979
310032......................................................      23.3017      24.3528      24.7404      24.1425
310034......................................................      21.6851      23.2729      24.1150      22.9962
310036......................................................      19.8178      20.1905      21.7187      20.5557
310037......................................................      27.4447      27.7823      28.1289      27.7758
310038......................................................      25.3832      26.7209      28.4893      26.9013
310039......................................................      22.0259      22.1754      22.7317      22.2988
310040......................................................      23.9864      26.1492      26.3573      25.4478
310041......................................................      23.7829      24.8960      23.5559      24.0709
310042......................................................      24.3292      23.2472      24.7678      24.1098
310043......................................................      22.0887      21.9022      21.6128      21.8925
310044......................................................      20.4309      21.6677      23.1549      21.6891
310045......................................................      28.1570      28.4854      28.9274      28.5212
310047......................................................      24.5225      25.1101      26.1921      25.2615
310048......................................................      23.3295      23.6118      25.2870      24.0821
310049......................................................      24.7617      24.8299      27.0842      25.4915
310050......................................................      22.5877      25.1752      24.7988      24.2032
310051......................................................      25.2762      27.1265      27.5378      26.5967
310052......................................................      22.5753      22.9326      23.3973      22.9809
310054......................................................      24.7413      26.1726      27.7376      26.1388
310057......................................................      20.4484      21.1686      22.2572      21.2802
310058......................................................      26.2243      26.5308      26.3765      26.3747
310060......................................................      19.1119      19.1992      20.0997      19.4729
310061......................................................      20.8023      23.2646      33.9582      25.0082
310062......................................................      19.2729      22.9073            *      21.3672
310063......................................................      21.8540      21.9045      22.1080      21.9521
310064......................................................      24.2115      24.8567      25.4822      24.8391
310067......................................................      22.2740      25.0888      23.9278      23.7333
310069......................................................      24.1662      23.7531      24.2329      24.0530
310070......................................................      25.0448      26.0903      28.2220      26.3630
310072......................................................      22.2231      21.7605      22.5611      22.1704
310073......................................................      25.6299      28.5149      26.2937      26.7849

[[Page 40002]]

 
310074......................................................      24.4638      23.8340      22.3588      23.6496
310075......................................................      26.4606      23.3266      24.4788      24.7522
310076......................................................      28.8981      30.0797      27.9918      29.0283
310077......................................................      25.0569      25.2500      26.1251      25.4460
310078......................................................      23.4788      23.8841      24.0587      23.7967
310081......................................................      23.8898      22.0762      22.4086      22.8084
310083......................................................      23.6761      23.8852      24.8204      24.1353
310084......................................................      24.0915      26.6753      24.6049      25.1157
310086......................................................      21.4350      22.1674      23.1719      22.2404
310087......................................................      20.8875      20.7243      21.1215      20.9125
310088......................................................      22.3419      22.3160      23.1722      22.6064
310090......................................................      24.2426      23.8284      24.8986      24.3109
310091......................................................      22.0103      22.7978      23.2969      22.6743
310092......................................................      22.3446      20.5165      21.6964      21.5200
310093......................................................      21.2302      22.4291      23.7251      22.4166
310096......................................................      26.3041      25.1572      24.5759      25.3591
310105......................................................      24.4851      25.5891      26.2537      25.4282
310108......................................................      22.8801      22.4756      23.8308      23.0488
310110......................................................      20.1400      21.8341      23.2146      21.7904
310111......................................................      21.7218       1.1066      22.1151      21.6430
310112......................................................      22.5213      23.6701      24.7914      23.6656
310113......................................................      22.9536      23.6841      23.1961      23.2803
310115......................................................      20.0667      21.7320      21.1645      20.9731
310116......................................................      25.2429      22.9812      23.6366      23.9253
310118......................................................      24.5443      26.4625      26.1315      25.6352
310119......................................................      29.4809      33.6686      32.7858      31.9394
310120......................................................      21.6852      23.9681      23.3200      22.9127
310121......................................................      18.7365            *            *      18.7365
320001......................................................      17.8522      19.1150      20.6225      19.1818
320002......................................................      22.4623      22.6175      23.0983      22.7062
320003......................................................      15.3484      15.9504      16.4642      15.9014
320004......................................................      17.2353      18.5824      19.6642      18.5890
320005......................................................      19.8698      21.6103      21.0411      20.8577
320006......................................................      18.6472      18.9019      20.3863      19.2674
320009......................................................      17.6400      18.2883      19.3500      18.4218
320011......................................................      16.5481      20.0601      18.5222      18.4330
320012......................................................      15.9972      16.4355      17.1764      16.5374
320013......................................................      23.8390      22.9573      24.5543      23.8179
320014......................................................      15.9666      16.3598      16.8412      16.4003
320016......................................................      18.9296      20.5398      18.8519      19.4293
320017......................................................      18.1545      18.6388      19.4498      18.7392
320018......................................................      18.1944      18.8479      19.2336      18.7690
320019......................................................      19.2600      24.4707      26.9637      23.5577
320021......................................................      17.1647      17.8705      19.0457      17.9920
320022......................................................      15.8391      16.1777      18.0606      16.7167
320023......................................................      16.4170      18.0548      17.8419      17.3761
320030......................................................      16.5266      16.5495      18.6859      17.1956
320031......................................................      13.9914      19.6768      25.1715      19.2605
320032......................................................      18.7536      18.8097      20.6871      19.3668
320033......................................................      20.3137      25.0777      21.0621      21.9427
320035......................................................      25.7392      21.5186      15.0612      19.2882
320037......................................................      17.0846      17.0305      17.8280      17.3203
320038......................................................      16.2896      16.8117      22.2664      18.6619
320046......................................................      19.0033      18.3190      18.9607      18.7526
320048......................................................      19.1705      19.9642      16.8769      18.5918
320063......................................................      19.8320      18.3237      17.9089      18.6049
320065......................................................      16.1046      16.7933      18.6525      17.1721
320067......................................................      57.4818      33.8654      15.3228      25.9798
320068......................................................      18.1809      17.4785      18.5103      18.1180
320069......................................................      11.3058      13.0094      14.4212      12.8497
320074......................................................      18.6545      19.3406      20.2290      19.3600
320079......................................................      17.0696      18.2828      19.8555      18.3645
330001......................................................      25.2067      26.5533      27.3996      26.4208

[[Page 40003]]

 
330002......................................................      26.3926      26.5370      26.9341      26.6121
330003......................................................      18.0549      19.4102      18.9211      18.7797
330004......................................................      19.9573      22.5298      20.9501      21.1368
330005......................................................      24.2795      24.8338      22.1957      23.2739
330006......................................................      25.9186      25.0576      25.8006      25.5856
330007......................................................      18.7956      18.9024            *      18.8475
330008......................................................      18.0684      19.0045      19.2341      18.7497
330009......................................................      30.4220      30.6918      31.3435      30.8056
330010......................................................      14.7382      17.4512      16.6508      16.1432
330011......................................................      18.0419      18.2986      18.6748      18.3483
330012......................................................      31.5135      32.7624            *      32.1317
330013......................................................      19.9929      19.0856      19.6269      19.5703
330014......................................................      27.5704      32.3370      36.8669      32.2778
330016......................................................      17.4069      16.9717      16.8016      17.0572
330019......................................................      32.4515      35.9822      33.5369      34.0043
330020......................................................      14.5488      15.5527      15.1142      15.0641
330023......................................................      24.2708      24.4006      25.6512      24.7835
330024......................................................      33.6175      34.1682      37.3316      34.9189
330025......................................................      16.0290      16.2033      16.8687      16.3599
330027......................................................      32.4959      33.4738      35.5255      33.7629
330028......................................................      27.0752      28.2089      29.5294      28.2349
330029......................................................      16.5552      18.1567      17.0016      17.2536
330030......................................................      15.0551      17.4977      19.1085      16.8779
330033......................................................      16.7497      18.5353      17.4444      17.6068
330034......................................................      30.7840      31.3997      27.7738      30.5701
330036......................................................      24.3239      23.9874      25.2820      24.5370
330037......................................................      16.0026      16.1140      16.4866      16.2081
330038......................................................      16.0153      16.2549      17.3429      16.5336
330039......................................................      12.4666            *            *      12.4666
330041......................................................      30.4192      24.5215      31.4871      28.4761
330043......................................................      27.6286      28.7467      27.4661      27.9537
330044......................................................      18.6969      20.0238      19.5219      19.4106
330045......................................................      27.1759      28.0758      27.9919      27.7401
330046......................................................      31.9802      32.4189      35.2703      33.1562
330047......................................................      17.6895      18.1815      18.5536      18.1416
330048......................................................      17.6239      17.8787      19.1093      18.1878
330049......................................................      19.3136      19.4993      20.5731      19.7930
330053......................................................      15.6659      17.4430      17.8082      16.9823
330055......................................................      30.7330      36.1109      32.8910      33.1680
330056......................................................      30.2206      30.4525      30.0945      30.2540
330057......................................................      18.6891      18.7478      19.3643      18.9410
330058......................................................      16.9805      17.0014      17.7672      17.2379
330059......................................................      32.2285      34.1705      34.2426      33.4744
330061......................................................      25.0674      25.7331      25.4082      25.4024
330062......................................................      15.2819      17.6067      18.1318      16.9856
330064......................................................      32.8724      33.1269      33.6447      33.2084
330065......................................................      18.3686      19.8940      19.9305      19.3468
330066......................................................      19.9455      19.5611      18.8707      19.4674
330067......................................................      21.2872      20.9443      22.1065      21.4528
330072......................................................      29.3096      30.8019      30.4171      30.1659
330073......................................................      15.8849      16.2898      16.4518      16.2013
330074......................................................      18.1636      18.0005      17.7308      17.9678
330075......................................................      17.4266      17.2298      17.6385      17.4324
330078......................................................      17.4863      16.7949      18.7884      17.6577
330079......................................................      16.7608      17.4555      18.7622      17.6535
330080......................................................      26.8766      29.2686      31.4424      29.0970
330084......................................................      23.0327      18.0435      19.3216      19.8703
330085......................................................      18.7835      20.2926      20.6203      19.8951
330086......................................................      30.6954      31.2980      23.6496      28.6407
330088......................................................      25.6160      25.6626      25.7940      25.6905
330090......................................................      18.6833      19.3954      19.2112      19.0937
330091......................................................      18.5334      19.0953      19.7776      19.1249
330092......................................................      12.6540      14.0671      13.3723      13.3059

[[Page 40004]]

 
330094......................................................      17.7196      17.5585      18.1582      17.8207
330095......................................................      18.5502      20.1073      21.1096      19.8197
330096......................................................      16.5963      17.9641      18.5149      17.6975
330097......................................................      16.9626      16.2169      16.4433      16.5145
330100......................................................      28.1060      27.0661      29.0916      28.0415
330101......................................................      31.3075      32.4105      31.5914      31.7153
330102......................................................      17.5230      17.5755      19.0058      18.0012
330103......................................................      16.5212      15.7197      16.8110      16.3435
330104......................................................      28.7669      31.6471      31.2074      30.5068
330106......................................................      35.8740      40.2686      35.3775      37.0516
330107......................................................      28.0780      28.5580      27.7797      28.1411
330108......................................................      17.0846      17.3605      18.0786      17.5050
330111......................................................      15.2047      19.5314      15.9321      16.7001
330114......................................................      18.2390      17.3522      17.0581      17.5626
330115......................................................      16.5581      17.4430      17.4684      17.1455
330116......................................................      24.2266      24.4622      14.9610      20.6732
330118......................................................      20.7550      20.6936            *      20.7240
330119......................................................      34.7478      34.8385      33.1179      34.2290
330121......................................................      15.8468      16.1052      16.3385      16.0964
330122......................................................      21.2021      20.8204      20.2417      20.7389
330125......................................................      19.7456      19.8494      19.7638      19.7865
330126......................................................      22.6990      23.7938      23.8957      23.4789
330127......................................................      29.3317      31.9046      30.7356      30.6271
330128......................................................      27.8693      29.0222      30.8242      29.1534
330132......................................................      14.7006      15.7633      14.3673      14.9673
330133......................................................      32.3812      37.2494      35.3576      34.8196
330135......................................................      18.3346      18.7120      22.2670      19.6717
330136......................................................      17.6041      18.2422      20.1043      18.6252
330140......................................................      19.5016      19.1438      19.3615      19.3334
330141......................................................      25.1371      26.4956      26.7096      26.0966
330144......................................................      15.5068      14.0566      16.2517      15.2343
330148......................................................      15.0400      16.8151      16.2782      16.0197
330151......................................................      13.9700      16.0714      15.7594      15.2313
330152......................................................      29.4818      30.5409      30.8314      30.2117
330153......................................................      17.4996      18.9689      18.1776      18.1944
330157......................................................      20.8239      22.0792      22.3804      21.7687
330158......................................................      26.0476      25.7569      27.1228      26.3184
330159......................................................      18.0211      19.1536      19.4998      18.8640
330160......................................................      30.5678      32.7840      29.5885      30.9340
330162......................................................      27.7162      27.1166      27.6010      27.4784
330163......................................................      20.4555      18.7816      20.7456      19.9795
330164......................................................      19.4831      19.8647      20.9003      20.0827
330166......................................................      14.1815      15.0954      15.4420      14.8722
330167......................................................      31.1834      29.3634      30.2346      30.2561
330169......................................................      33.4462      37.2655      35.4794      35.3665
330171......................................................      25.4314      25.5307      24.8035      25.2597
330175......................................................      16.6851      17.3290      18.3116      17.4443
330177......................................................      14.5378      17.2907      16.3704      16.0830
330179......................................................      12.6857      13.4999      13.8953      13.3684
330180......................................................      15.5304      16.8787      17.9877      16.7426
330181......................................................      32.4718      32.5192      33.0908      32.6900
330182......................................................      30.9260      32.9371      33.6531      32.5479
330183......................................................      19.9964      19.9207      20.6164      20.1809
330184......................................................      27.4859      30.0400      31.3706      29.6316
330185......................................................      26.9496      25.6112      26.8612      26.4537
330188......................................................      18.7208      20.9587      18.8000      19.4696
330189......................................................      17.6585      15.1253      18.4498      16.9610
330191......................................................      18.8586      18.6206      19.0348      18.8384
330193......................................................      29.8042      36.5481      30.2260      31.8162
330194......................................................      35.5748      34.6785      35.2036      35.1664
330195......................................................      31.3915      33.3254      34.8966      33.0747
330196......................................................      28.4465      30.8165      30.5799      29.9142
330197......................................................      16.9990      17.6646      18.3527      17.6922

[[Page 40005]]

 
330198......................................................      23.8113      24.6038      24.8590      24.4203
330199......................................................      27.6605      28.7609      30.5409      28.9499
330201......................................................      30.3293      32.1149      28.7861      30.4144
330202......................................................      30.7869      31.4435      31.2575      31.1487
330203......................................................      19.2353      20.7575      25.0345      21.5038
330204......................................................      29.3662      29.4418      32.2005      30.2707
330205......................................................      19.4642      20.5793      22.3490      20.7832
330208......................................................      25.8201      26.1822      26.6682      26.2220
330209......................................................      24.8834      23.9924      25.1281      24.6749
330211......................................................      19.0968      19.5064      19.5405      19.3836
330212......................................................      21.1777      21.7705      24.7681      22.5597
330213......................................................      18.5066      18.7722      19.6796      18.9552
330214......................................................      32.1966      36.4447      32.4292      33.4440
330215......................................................      17.5818      19.6926      17.9863      18.3902
330218......................................................      21.7072      21.4796      21.1890      21.4557
330219......................................................      22.1476      23.9908      23.4310      23.1411
330221......................................................      32.2081      27.8485      33.3796      31.2840
330222......................................................      17.8140      18.3666      18.5571      18.2482
330223......................................................      17.2754      17.6199      17.8306      17.5845
330224......................................................      21.9728      19.6410      20.4309      20.7047
330225......................................................      25.8043      25.5823      27.0379      26.0910
330226......................................................      17.6708      16.6711      23.1859      18.8241
330229......................................................      16.2509      16.8026      17.5326      16.8453
330230......................................................      28.8625      29.7626      29.6283      29.3810
330231......................................................      29.0917      30.0923      32.7200      30.4677
330232......................................................      19.5042      17.9083      19.1787      18.8569
330233......................................................      33.3008      30.9241      44.1265      35.0751
330234......................................................      33.3286      35.1777      35.0720      34.4830
330235......................................................      19.4532      21.0842      19.5880      20.0417
330236......................................................      30.7017      29.5913      31.3463      30.5397
330238......................................................      14.7951      15.6245      17.3976      15.9047
330239......................................................      17.2808      17.4462      18.5079      17.7328
330240......................................................      30.4765      29.7082      30.7321      30.2841
330241......................................................      22.6046      24.6076      23.8638      23.6409
330242......................................................      24.7401      28.2612      27.6384      26.8305
330245......................................................      17.2803      17.6767      18.5161      17.8488
330246......................................................      26.6587      28.1090      28.1205      27.6612
330247......................................................      27.6203      28.5310      27.3937      27.8277
330249......................................................      16.4818      16.2687      17.1320      16.6304
330250......................................................      19.5553      19.5823      19.9619      19.7058
330252......................................................      17.0379            *            *      17.0379
330254......................................................      16.7252      18.4057      15.9123      17.0146
330258......................................................      30.4656      29.7426      31.8910      30.6921
330259......................................................      25.2526      26.2661      25.9994      25.8364
330261......................................................      26.1654      25.7244      27.9766      26.6137
330263......................................................      19.6388      20.4149      18.7378      19.6517
330264......................................................      23.1359      22.8672      22.8099      22.9301
330265......................................................      15.6249      18.0193      17.6301      17.0414
330267......................................................      23.5561      24.5183      24.5939      24.2287
330268......................................................      14.6249      13.0595      15.9060      14.5364
330270......................................................      28.2392      34.4254      36.0824      32.6382
330273......................................................      25.8910      23.1511      26.0565      24.9430
330275......................................................      17.4223      19.0548      18.7268      18.3387
330276......................................................      17.7452      18.2870      19.0228      18.3342
330277......................................................      17.1570      18.3169      19.1761      18.2131
330279......................................................      19.9079      19.5983      20.7107      20.0436
330285......................................................      22.4717      23.5264      24.0491      23.3509
330286......................................................      25.0948      26.7633      27.7762      26.5916
330290......................................................      32.5792      33.5056      30.4706      32.2470
330293......................................................      15.3782      16.2158      16.9238      16.1248
330304......................................................      29.3687      26.7683      27.3562      27.8227
330306......................................................      27.6214      27.3798      29.5937      28.1525
330307......................................................      20.7362      21.0673      21.7257      21.1725

[[Page 40006]]

 
330308......................................................      36.8361            *            *      36.8361
330314......................................................      24.7399      24.5444      25.9937      25.0514
330316......................................................      28.7872      27.6102      27.9543      28.1177
330327......................................................      16.9724      16.4611      20.3874      17.9258
330331......................................................      31.0405      31.6216      33.1276      32.0298
330332......................................................      27.1554      27.6914      25.3689      26.7855
330333......................................................            *      29.1931            *      29.1931
330336......................................................      30.1708      29.7689      29.8294      29.9290
330338......................................................      23.0077      22.4581      21.2670      22.2755
330339......................................................      19.6730      20.0111      20.1028      19.9220
330340......................................................      26.9201      28.8419      28.4129      28.0687
330350......................................................      30.3754      30.8889      30.9763      30.7427
330353......................................................      33.5519      32.1984      34.2431      33.3163
330357......................................................      34.7492      36.5928      34.1846      35.2059
330359......................................................      29.2920            *            *      29.2920
330372......................................................      22.5027      28.8482      33.3771      27.5982
330381......................................................      29.2438      31.0091      31.8602      30.6612
330385......................................................      28.8373      35.6722      33.2246      32.4207
330386......................................................      24.6713      17.6383      20.4231      20.5236
330389......................................................      32.4234      30.2505      37.3749      32.9392
330390......................................................      29.7936      31.1577      30.8744      30.5843
330393......................................................      27.9901      26.4958      27.8352      27.4232
330394......................................................      18.7724      19.2392      18.9343      18.9816
330395......................................................      37.6805      32.8749      32.7494      34.3792
330396......................................................      30.7228      34.8648      30.7961      32.1685
330397......................................................      31.0043      33.9061      32.6068      32.3768
330398......................................................      30.3217      28.7707      29.2872      29.6846
330399......................................................      35.5212      32.9100      33.3012      33.9214
330400......................................................            *            *      16.2707      16.2707
340001......................................................      19.0159      18.1814      19.7093      18.9605
340002......................................................      18.7790      20.8858      20.5253      20.0921
340003......................................................      21.9674      20.2540      19.5145      20.4958
340004......................................................      17.8923      19.0695      20.9863      19.3245
340005......................................................      14.0941      15.8205      16.7176      15.5039
340006......................................................      17.8145      16.9818      16.5709      17.0955
340007......................................................      17.1708      17.2356      18.3399      17.5929
340008......................................................      18.3769      21.2889      20.4157      20.0279
340009......................................................      20.5011      20.5023      20.9178      20.6132
340010......................................................      17.6500      18.3380      19.4302      18.4900
340011......................................................      14.9215      13.6554      14.4798      14.3110
340012......................................................      16.6574      18.8701      17.5112      17.6905
340013......................................................      17.4302      20.1747      19.4613      19.0754
340014......................................................      19.9203      20.5748      27.7888      22.1408
340015......................................................      19.0056      20.1562      19.4676      19.5517
340016......................................................      16.3977      17.5404      18.8958      17.5664
340017......................................................      19.2203      19.4192      20.2775      19.6581
340018......................................................      15.1579      14.0930      18.1751      15.6569
340019......................................................      13.5919      14.8980      15.2887      14.5682
340020......................................................      16.7515      18.6334      18.0897      17.8512
340021......................................................      19.6658      19.8020      20.5813      20.0277
340022......................................................      16.7211      17.8178      18.7714      17.7886
340023......................................................      17.2054      18.5414      19.3146      18.3540
340024......................................................      16.6389      17.3824      17.9130      17.3104
340025......................................................      16.8198      17.2648      18.4628      17.5179
340027......................................................      17.2971      18.0816      19.4548      18.2602
340028......................................................      17.7196      18.4787      19.9403      18.7490
340030......................................................      20.0530      21.1420      22.4709      21.2046
340031......................................................      12.3895      14.6951      14.6370      13.8761
340032......................................................      20.4735      20.0049      20.7444      20.4083
340035......................................................      18.0988      20.2312      18.9930      19.1067
340036......................................................      16.9674      18.2190      17.7619      17.6323
340037......................................................      15.5347      16.6576      17.5829      16.5842
340038......................................................      17.0154      17.3762      18.1493      17.5050

[[Page 40007]]

 
340039......................................................      20.1470      20.5876      21.3711      20.7125
340040......................................................      20.1214      20.4282      20.7237      20.4264
340041......................................................      17.7626      15.1419      15.5873      16.0395
340042......................................................      16.6300      16.9298      17.0034      16.8680
340044......................................................      16.3657      18.8687      18.0863      17.7757
340045......................................................      12.4152      13.0538      13.6182      12.9769
340047......................................................      19.6050      20.0602      20.0744      19.9132
340049......................................................      16.4988      19.2050      19.5127      18.2917
340050......................................................      18.5570      20.0090      19.6726      19.4142
340051......................................................      18.5953      16.5617      19.3627      18.0980
340052......................................................      21.3746      22.8173      23.2134      22.4161
340053......................................................      19.4881      20.9495      19.9915      20.1403
340054......................................................      14.4722      15.5993      15.5090      15.2167
340055......................................................      18.1786      19.6056      19.4035      19.0752
340060......................................................      17.9167      18.7137      19.3410      18.6670
340061......................................................      20.8474      21.5385      22.1175      21.4855
340063......................................................      16.9232      17.0249      16.7377      16.9005
340064......................................................      17.2584      20.7125      18.5069      18.8299
340065......................................................      18.3212      17.5414      17.3530      17.7394
340067......................................................      18.6132      19.3785      19.7187      19.2365
340068......................................................      16.7015      16.6305      17.8065      17.0483
340069......................................................      19.9948      21.0840      21.6728      20.9166
340070......................................................      18.6270      19.7796      20.6829      19.7122
340071......................................................      16.3701      17.1424      18.0767      17.2043
340072......................................................      15.6014      16.7400      17.7129      16.7307
340073......................................................      20.6905      21.9761      23.5832      22.0016
340075......................................................      18.2060      18.7090      20.0081      18.9541
340080......................................................      16.8453      22.2533      18.2061      19.0642
340084......................................................      21.7813      17.1532      19.0103      19.0182
340085......................................................      16.2355      17.3462      18.3179      17.3020
340087......................................................      16.6987      17.3884      18.2255      17.4652
340088......................................................      19.8314      21.0226      22.2322      21.0156
340089......................................................      13.8633      13.8535      15.4760      14.4308
340090......................................................      17.8457      17.0584      18.5287      17.8139
340091......................................................      19.3955      20.5923      20.3861      20.1343
340093......................................................      15.1615      16.3276      16.8903      16.0870
340094......................................................      15.9568      19.0406            *      17.4328
340096......................................................      17.9764      17.8189      19.4696      18.4348
340097......................................................      21.3700      18.8412      18.2399      19.4192
340098......................................................      20.1671      21.4135      21.9578      21.2065
340099......................................................      15.0888      16.8305      15.3752      15.7269
340101......................................................      15.3610      13.9994      15.6509      14.9555
340104......................................................      15.8729      13.0462      11.5169      13.4465
340105......................................................      18.9007      20.2954            *      19.5963
340106......................................................      18.0769      17.7220      18.1211      17.9704
340107......................................................      16.9503      18.0205      19.3197      18.0904
340109......................................................      17.9576      18.7746      19.0532      18.6067
340111......................................................      14.9247      16.3344      16.5976      15.9665
340112......................................................      14.5966      14.7562      15.5142      14.9625
340113......................................................      20.8821      21.2906      21.9883      21.3854
340114......................................................      20.8195      21.2166      20.7261      20.9197
340115......................................................      18.6700      19.7578      21.7586      20.0594
340116......................................................      19.4786      20.4255      20.6800      20.2116
340119......................................................      16.8537      18.8507      19.5827      18.4595
340120......................................................      14.3822      15.0410      15.8240      15.1047
340121......................................................      15.9686      16.3295      17.8771      16.7251
340123......................................................      16.2227      16.9114      18.9078      17.3848
340124......................................................      14.0462      15.5779      17.4185      15.7171
340125......................................................      19.6252      19.7164      20.2748      19.8633
340126......................................................      17.7214      18.8100      19.3734      18.6747
340127......................................................      17.3849      19.3925      19.3842      18.7105
340129......................................................      19.7332      20.4605      20.6521      20.2893
340130......................................................      19.4430      19.7422      19.8707      19.6940

[[Page 40008]]

 
340131......................................................      18.9361      19.7908      21.3849      20.0481
340132......................................................      16.9369      17.3448      17.5711      17.3015
340133......................................................      14.3501      16.4766      17.2138      16.0568
340137......................................................            *      21.0249      31.7702      23.8273
340138......................................................      19.2807      20.7618            *      20.0092
340141......................................................      22.2234      21.3754      21.4986      21.6898
340142......................................................      16.0912      17.1525      18.0766      17.1107
340143......................................................      20.9509      21.3604      24.4098      22.2423
340144......................................................      19.1919      20.9113      22.9183      20.9333
340145......................................................      19.1964      20.1081      19.9233      19.7573
340146......................................................      13.0119      15.9203      17.3051      15.3284
340147......................................................      19.1087      19.6827      20.5520      19.8121
340148......................................................      18.4227      18.5875      18.9912      18.6555
340151......................................................      16.5671      16.7275      18.4733      17.2579
340153......................................................      20.6588      20.6420      20.7533      20.6847
340155......................................................      20.4236      20.5792      23.1021      21.3418
340158......................................................      17.2565      18.1439      19.0843      18.2232
340159......................................................      16.8048      17.3893      19.0338      17.7595
340160......................................................      15.5298      16.1778      16.7170      16.1477
340162......................................................      16.6362      14.3472            *      16.3541
340164......................................................      19.6820      21.2523      21.5769      20.8240
340166......................................................      19.1743      20.0434      20.8270      20.0663
340168......................................................      14.7508      15.2919      15.6071      15.2494
340171......................................................      20.0495      21.5973      22.4779      21.4041
340173......................................................      20.2132      19.3353      21.0898      20.2512
350001......................................................      11.7345      14.9080      16.6551      14.4005
350002......................................................      17.2834      17.5259      18.3459      17.7122
350003......................................................      17.4276      18.2470      19.2840      18.3041
350004......................................................      17.9049      20.6518      23.7016      20.6528
350005......................................................      16.0259      18.3792      19.9156      18.1833
350006......................................................      16.6241      18.4107      19.0343      17.9691
350007......................................................      13.2771      13.3292      13.8824      13.4842
350008......................................................      21.6983      20.4777      22.3783      21.4889
350009......................................................      18.2818      19.1611      18.3688      18.6099
350010......................................................      15.2762      16.2808      16.6272      16.0505
350011......................................................      18.4931      18.2008      19.1944      18.6474
350012......................................................      12.7287      15.7033      18.2524      15.6975
350013......................................................      16.6784      16.4579      17.2596      16.7923
350014......................................................      15.7906      16.8403      18.0999      16.8354
350015......................................................      15.8651      16.3397      17.1071      16.3998
350016......................................................      11.6255      11.6524            *      11.6395
350017......................................................      17.7835      17.6278      17.5124      17.6446
350018......................................................      13.6366      14.4928      16.4939      14.8276
350019......................................................      19.4037      19.3063      20.1608      19.6008
350021......................................................      12.6885      16.2898      17.7123      15.5294
350023......................................................      12.7952      17.9048      17.4983      16.4355
350024......................................................      14.3740      14.7529      15.4788      14.8361
350025......................................................      16.2400      17.1199      15.0469      16.0889
350027......................................................      17.1177      15.0835      15.5178      15.9200
350029......................................................      12.7950      13.5219      14.6173      13.6002
350030......................................................      17.3497      17.7209      18.1131      17.7195
350033......................................................      14.8953      14.9012      16.0870      15.2715
350034......................................................      18.3180      18.7245      19.6445      18.8742
350035......................................................      10.1561      10.4570      11.7675      10.7676
350038......................................................      18.7357      17.6666      19.6854      18.6648
350039......................................................      17.3128      17.0361      16.6278      17.0024
350041......................................................      14.6772      14.6680      19.1341      15.9095
350042......................................................      16.7544      16.7402      19.3309      17.4345
350043......................................................      17.1573      16.8876      16.7433      16.9224
350044......................................................      10.5296      10.2154      11.0601      10.5801
350047......................................................      17.9270      14.4628      18.0094      16.8202
350049......................................................      14.5330      14.8019      18.1993      15.6280
350050......................................................      10.5733      11.4921      12.2183      11.3924

[[Page 40009]]

 
350051......................................................      17.5323      17.7279      17.0653      17.4458
350053......................................................      13.9379      14.6398      15.9160      14.8075
350055......................................................      12.3722      14.5691      15.7916      14.3152
350056......................................................      14.7382      14.8293      15.0995      14.8885
350058......................................................      14.3484      15.9378      16.7034      15.7009
350060......................................................       9.5962      10.3666      10.3076      10.0926
350061......................................................      14.5894      15.7269      18.8790      16.4237
360001......................................................      17.3933      17.0791      19.6655      18.0423
360002......................................................      17.3955      18.0139      18.2613      17.9462
360003......................................................      22.0351      22.7471      22.7521      22.5117
360006......................................................      22.0906      21.8048      22.4436      22.1137
360007......................................................      17.0955      18.0941      14.8213      16.6387
360008......................................................      17.8185      18.5439      18.7961      18.3915
360009......................................................      17.5328      18.9322      18.9935      18.4667
360010......................................................      18.0886      19.2288      19.1852      18.8325
360011......................................................      18.9491      19.3835      21.3659      19.9105
360012......................................................      19.2221      19.9881      20.0525      19.7649
360013......................................................      20.8112      20.6021      21.3690      20.9190
360014......................................................      19.8844      20.2390      20.7419      20.2907
360016......................................................      18.7709      17.8065      21.2505      19.1632
360017......................................................      22.4972      21.7543      22.2740      22.1696
360018......................................................      21.3436      23.5219      24.6686      23.0168
360019......................................................      20.1726      18.7147      20.6480      19.8139
360020......................................................      22.9512      21.7806      22.1751      22.3268
360024......................................................      18.5412      19.8508      20.1352      19.5008
360025......................................................      19.2918      20.3638      20.2531      19.9763
360026......................................................      17.0378      18.2222      17.9523      17.7450
360027......................................................      20.3568      21.0406      21.7650      21.0544
360028......................................................      17.2681      17.0177      18.7174      17.5937
360029......................................................      18.2193      18.7622      19.2928      18.7626
360030......................................................      15.3535      17.5748      17.6058      16.8173
360031......................................................      19.8987      19.3858      21.0687      20.1028
360032......................................................      17.9274      18.6559      19.8020      18.7667
360034......................................................      15.5649      14.9534      17.9594      16.1258
360035......................................................      20.3358      20.5557      21.0674      20.6574
360036......................................................      19.1835      20.2107      20.9916      20.1250
360037......................................................      22.5240      23.5094      23.1674      23.0445
360038......................................................      19.8921      21.2467      19.9415      20.3576
360039......................................................      17.4033      18.7791      19.0013      18.5872
360040......................................................      18.1238      18.1618      18.7425      18.3503
360041......................................................      18.4244      19.5744      19.7968      19.2697
360042......................................................      16.1187      17.4306      17.1952      16.9328
360044......................................................      16.7925      17.0612      17.6882      17.1993
360045......................................................      21.1814      22.1471      22.4018      21.8209
360046......................................................      19.3198      20.4755      20.4607      20.0909
360047......................................................      15.3399      17.1871      15.2922      15.8884
360048......................................................      21.1719      22.5857      22.4890      22.0646
360049......................................................      18.8084      20.4564      20.8393      20.0008
360050......................................................      12.8888      12.9873      15.0568      13.6080
360051......................................................      20.9461      20.8338      20.8757      20.8844
360052......................................................      20.0182      19.6233      18.7931      19.5088
360054......................................................      16.1875      17.2574      17.4911      16.9860
360055......................................................      23.2671      21.5585      21.4112      22.0925
360056......................................................      18.7606      19.0474      20.6968      19.5385
360057......................................................      13.8094      15.0146      15.8569      14.8518
360058......................................................      17.9178      18.6992      19.3306      18.6392
360059......................................................      21.9689      20.5618      19.9304      20.8679
360062......................................................      20.3111      20.7588      21.9195      20.9548
360063......................................................      22.7866      18.4512      17.5108      19.4998
360064......................................................      20.6416      20.4846      20.0615      20.4087
360065......................................................      19.4531      20.0532      19.6199      19.7128
360066......................................................      20.0285      21.6015      22.8175      21.4937
360067......................................................      14.5687      15.3157      14.2745      14.7189

[[Page 40010]]

 
360068......................................................      21.2199      21.2789      22.6227      21.7164
360069......................................................      17.8329      16.6982      14.6597      16.2292
360070......................................................      17.5300      17.3758      18.8406      17.9171
360071......................................................      23.8013      17.9756      19.0302      20.2494
360072......................................................      17.9697      18.1467      19.0166      18.3995
360074......................................................      18.2614      20.8275      18.5889      19.1849
360075......................................................      18.4733      22.4523      26.0663      21.4074
360076......................................................      19.5864      20.0700      20.3317      20.0010
360077......................................................      20.8202      21.1053      21.5517      21.1550
360078......................................................      20.7940      21.4392      22.6490      21.6280
360079......................................................      22.0033      22.1096      21.6644      21.9274
360080......................................................      16.6414      17.3892      17.6369      17.2080
360081......................................................      19.6354      21.7342      20.4614      20.6451
360082......................................................      22.8585      22.9460      20.7610      22.1460
360083......................................................      18.4635            *            *      18.4635
360084......................................................      20.0914      20.4894      22.0492      20.8664
360085......................................................      21.6670      21.9051      21.5151      21.7121
360086......................................................      17.0389      19.5378      19.3701      18.5836
360087......................................................      20.0395      20.1684      20.7969      20.3249
360088......................................................      22.3121      24.0097      24.0822      23.4637
360089......................................................      20.5610      18.3881      18.1941      19.0415
360090......................................................      20.3955      21.0376      20.8971      20.7887
360091......................................................      21.0335      21.3126      21.8447      21.4132
360092......................................................      15.9095      20.4534      21.5073      18.9727
360093......................................................      18.5744      19.3292      19.0261      18.9905
360094......................................................      18.3105      18.8780      20.1227      19.0848
360095......................................................      18.7079      20.4149      19.8521      19.6643
360096......................................................      17.1617      18.2215      19.6726      18.3160
360098......................................................      18.3361      19.5314      19.8178      19.2371
360099......................................................      18.5523      18.5855      19.6241      18.9389
360100......................................................      17.6554      17.8989      18.0442      17.8625
360101......................................................      22.3121      21.3914      20.2635      21.3487
360102......................................................      19.7700      19.4345      18.5367      19.2837
360103......................................................      22.6228            *            *      22.6228
360106......................................................      16.1843      18.9752      19.1778      18.1964
360107......................................................      18.6195      19.7599      22.1359      20.1794
360108......................................................      16.5076      17.5832      20.0681      18.0497
360109......................................................      19.5162      20.1032      19.9237      19.8530
360112......................................................      22.5676      22.5589      24.6335      23.2167
360113......................................................      22.4584      24.2654      20.8154      22.4061
360114......................................................      16.3288      17.8761      18.7509      17.6758
360115......................................................      18.1859      18.8059      20.7652      19.2888
360116......................................................      18.0835      18.8882      18.8319      18.6000
360118......................................................      18.6098      19.3732      19.9141      19.3196
360121......................................................      21.0979      22.1093      22.2175      21.8088
360123......................................................      19.1313      20.3236      20.9792      20.1480
360125......................................................      18.1756      19.0774      20.5508      19.2432
360126......................................................      20.4558      19.0036      24.5387      21.1181
360127......................................................      16.9228      17.5882      16.5559      16.9955
360128......................................................      15.5823      16.1243      17.0515      16.2361
360129......................................................      15.5241      15.5002      16.6114      15.8783
360130......................................................      15.3356      17.2009      18.4539      16.9275
360131......................................................      18.2897      19.2241      18.4688      18.6543
360132......................................................      18.2733      19.9171      21.3493      19.8413
360133......................................................      19.0349      19.4316      20.2857      19.5509
360134......................................................      20.2383      20.6876      20.9564      20.6143
360136......................................................      17.8473      17.7827      18.2194      17.9464
360137......................................................      20.2581      20.1756      22.3648      20.9095
360140......................................................      19.1263      20.2791      21.2881      20.2299
360141......................................................      22.8496      23.0016      23.5343      23.1176
360142......................................................      17.3154      17.0059      18.3188      17.5468
360143......................................................      20.4378      20.1989      21.0336      20.5552
360144......................................................      21.9159      23.2191      20.9033      21.9858

[[Page 40011]]

 
360145......................................................      19.3907      19.6413      20.0513      19.6956
360147......................................................      16.5898      16.6616      17.6779      16.9779
360148......................................................      18.8914      19.2816      19.1393      19.1100
360149......................................................      18.7891      19.9808            *      19.3785
360150......................................................      20.6253      21.1327      22.3620      21.3641
360151......................................................      17.4863      16.6019      19.2788      17.7101
360152......................................................      21.9978      20.8328      21.6005      21.4611
360153......................................................      14.8948      15.4132      16.7399      15.6460
360154......................................................      13.7761      14.3270      14.3593      14.1608
360155......................................................      20.8977      22.5347      22.2112      21.8776
360156......................................................      17.9155      17.8787      18.9095      18.2225
360159......................................................      20.7119      20.2841      21.5695      20.8609
360161......................................................      19.4122      19.1983      20.6160      19.7228
360162......................................................      18.6084            *            *      18.6084
360163......................................................      20.3821      20.7275      21.2689      20.8164
360164......................................................      16.1643            *            *      16.1643
360165......................................................      19.4831      18.2571      18.2417      18.6524
360166......................................................      16.9778      18.7321            *      17.8568
360170......................................................      17.1779      16.4653      20.4407      17.9153
360172......................................................      18.4690      18.6720      19.8909      19.1486
360174......................................................      19.0887      19.9725      20.5399      20.0142
360175......................................................      20.4133      21.1685      21.5450      21.0739
360176......................................................      15.4730      15.9430      16.6228      16.0305
360177......................................................      19.4122      18.7898      18.9576      19.0368
360178......................................................      17.3985      18.8704      16.7962      17.7254
360179......................................................      19.1417      21.1309      20.7069      20.2966
360180......................................................      22.0949      21.3826      21.0146      21.4888
360184......................................................      19.3502      19.1224            *      19.2391
360185......................................................      18.6697      18.7291      19.4858      18.9599
360186......................................................      20.8579      18.3246      20.7572      19.9570
360187......................................................      18.0209      18.5109      19.6535      18.7427
360188......................................................      17.5327      17.1044      18.3057      17.6838
360189......................................................      17.3713      17.8981      18.5940      17.9373
360192......................................................      20.9980      21.6365      22.7846      21.8042
360193......................................................      17.6874            *            *      17.6874
360194......................................................      17.6890      17.1884      17.6140      17.4968
360195......................................................      19.0173      19.9302      20.5828      19.8368
360197......................................................      19.4250      20.0603      20.5062      19.9981
360200......................................................      17.7583      16.2306      17.9623      17.3129
360203......................................................      15.6212      16.3181      15.9609      15.9716
360204......................................................      19.3543      22.2494            *      20.5754
360210......................................................      20.2809      20.9955      21.8629      21.0428
360211......................................................      19.5762      19.9895      20.6081      20.0860
360212......................................................      20.2288      21.1123      20.6987      20.6781
360213......................................................      18.3253      19.4765      19.0584      18.9547
360218......................................................      18.4140      18.9469      18.8204      18.7231
360230......................................................      21.4385      21.9763      20.8042      21.3850
360231......................................................      13.5586      12.9588      14.4168      13.6102
360234......................................................      22.4324      23.2588      20.6131      22.0967
360236......................................................      19.4881      17.8426      21.4628      19.5088
360239......................................................      19.8584      20.1854      19.2375      19.7767
360241......................................................      22.0795      23.5318      25.3741      23.5406
360243......................................................      13.5835      14.8694            *      14.2018
360244......................................................      10.5518            *            *      10.5518
360245......................................................      15.0579      16.4622      15.9782      15.8310
360247......................................................      18.1116      16.3092      17.0776      17.0967
360248......................................................      21.6499            *            *      21.6499
360249......................................................            *            *      25.4331      25.4331
370001......................................................      21.2714      22.5214      24.1929      22.6419
370002......................................................      14.0847      14.7315      15.4333      14.7194
370004......................................................      16.7671      19.3236      18.5233      18.1546
370005......................................................      17.3817      15.1654      15.3881      15.9167
370006......................................................      12.9493      16.6484      16.4995      15.3118

[[Page 40012]]

 
370007......................................................      17.1535      15.2905      15.8312      16.0498
370008......................................................      17.3048      16.6566      17.5553      17.1688
370011......................................................      14.6397      14.9701      15.6178      15.0345
370012......................................................      10.8003      11.7265      12.4942      11.6228
370013......................................................      18.0385      19.3398      18.9584      18.7911
370014......................................................      19.6543      20.6512      20.2858      20.2276
370015......................................................      17.8247      17.0319      20.8765      18.5256
370016......................................................      16.6401      19.1191      19.1613      18.3470
370017......................................................      12.9837      12.6400      13.6531      13.1239
370018......................................................      14.2438      18.5107      17.7054      16.6955
370019......................................................      16.8801      14.2277      14.6216      15.1546
370020......................................................      13.4787      14.3798      15.1035      14.3356
370021......................................................      11.2639      12.0474      12.9030      12.0738
370022......................................................      17.9015      17.2344      17.3724      17.4872
370023......................................................      16.8215      17.7630      17.5148      17.3665
370025......................................................      16.3970      17.4988      18.4815      17.4661
370026......................................................      16.8991      18.3371      18.0412      17.7563
370028......................................................      19.7118      18.4445      21.1292      19.7322
370029......................................................      13.8930      16.4924      18.2580      16.0663
370030......................................................      15.4736      16.3269      16.5803      16.1058
370032......................................................      16.6432      18.2821      18.1538      17.7030
370033......................................................      12.3910      13.5216      11.3210      12.4595
370034......................................................      14.5101      15.6386      15.6288      15.2811
370035......................................................      18.9629      25.5764            *      21.9610
370036......................................................      11.4593      12.4026      12.4070      12.0833
370037......................................................      17.7491      16.7012      18.9556      17.7764
370038......................................................      12.8135      13.3084      13.0210      13.0660
370039......................................................      16.2661      15.5206      19.4498      17.0406
370040......................................................      14.2582      14.4672      15.5109      14.7638
370041......................................................      17.4123      16.7356      16.2316      16.8488
370042......................................................      14.6146      14.9175      15.2764      14.9764
370043......................................................      16.0764      15.9534      17.0892      16.3549
370045......................................................      12.4352      10.1994      11.3560      11.2236
370046......................................................      18.1499      18.8334            *      18.4831
370047......................................................      15.6716      16.7554      17.8769      16.7444
370048......................................................      17.4356      18.2150      15.6803      17.1206
370049......................................................      19.8397      20.7176      19.4868      19.9892
370051......................................................      12.1816      11.6736      12.5171      12.1083
370054......................................................      16.5598      16.9049      18.0787      17.1343
370056......................................................      18.8774      18.4558      18.1432      18.4804
370057......................................................      14.6564      16.7261      15.1228      15.5054
370059......................................................      16.4578      18.1386      18.3314      17.6259
370060......................................................      15.1169      16.5403      19.3051      16.8157
370063......................................................      17.0645      14.4132      16.7342      16.0603
370064......................................................       8.7499      10.9676      11.9954      10.6741
370065......................................................      16.5638      16.6898      18.1349      17.1281
370071......................................................      14.9472      16.1439      16.4567      15.8354
370072......................................................      14.6497      14.4742      13.6519      14.2760
370076......................................................      12.8568      13.5694      14.3555      13.5818
370077......................................................      17.6236            *            *      17.6236
370078......................................................      17.2370      18.4086      19.2412      18.2505
370079......................................................      13.5976      16.6861      16.9201      15.7005
370080......................................................      14.3445      13.9239      14.7323      14.3058
370082......................................................      13.5434      13.9634      15.0669      14.1855
370083......................................................      11.4905      13.1519      13.1810      12.6268
370084......................................................      21.7484      22.0545      13.1197      17.8063
370085......................................................      11.8844      11.2842      48.1271      14.9179
370086......................................................      13.5646      15.4404      11.1900      13.1933
370089......................................................      14.4968      16.0966      17.2638      15.9758
370091......................................................      17.5839      19.1698      20.1822      18.9743
370092......................................................      14.6757      14.9802      15.7678      15.1529
370093......................................................      18.5747      18.4600      19.7008      19.0469
370094......................................................      18.3796      18.0002      19.5462      18.6588

[[Page 40013]]

 
370095......................................................      14.1319      12.6383      13.4202      13.3755
370097......................................................      23.3116      22.9714      23.2056      23.1716
370099......................................................      16.2649      15.4549      19.4646      16.8783
370100......................................................      17.1036      14.0168      18.8274      16.6764
370103......................................................      15.8967      19.2353      18.2685      17.7516
370105......................................................      17.6811      21.3352      20.7890      19.9853
370106......................................................      18.6238      18.5485      20.3651      19.1398
370108......................................................      12.2379      12.3279      12.7470      12.4421
370112......................................................      15.2488      14.8539      15.3039      15.1287
370113......................................................      16.2043      16.1046      17.6107      16.6143
370114......................................................      15.9801      16.5268      17.8941      16.8136
370121......................................................      19.5506      22.5611      21.3099      21.1472
370122......................................................      12.1514      15.0645      15.4375      13.9736
370123......................................................      16.3609      18.9159      19.0313      18.0343
370125......................................................      13.5453      15.6284      13.9436      14.3107
370126......................................................      18.2447      23.9654      15.8020      19.1824
370131......................................................      16.2403      17.5689      15.7261      16.4650
370133......................................................      10.0169      10.9575      12.9545      11.1921
370138......................................................      15.9372      16.4005      17.5551      16.6500
370139......................................................      13.3023      14.8612      14.9964      14.3624
370140......................................................      15.2265      16.0721      17.1393      16.1657
370141......................................................      12.1420      18.4101      20.7798      16.3574
370146......................................................      12.5581      12.6402      13.0399      12.7467
370148......................................................      16.4147      20.6458      20.6612      19.2220
370149......................................................      16.7218      16.1850      17.0929      16.6647
370153......................................................      15.3218      17.8352      16.4669      16.5507
370154......................................................      15.9128      15.5127      15.6093      15.6789
370156......................................................      13.6363      13.9255      14.5696      14.0273
370158......................................................      15.0865      15.6917      15.6994      15.4906
370159......................................................      17.8319      28.0536      21.1267      21.7006
370163......................................................      14.5609      17.6361      20.4217      17.2893
370165......................................................      13.2174      13.0910      13.0375      13.1156
370166......................................................      17.8154      17.2849      21.0797      18.6456
370169......................................................       9.4807      12.5243      12.7138      11.5273
370176......................................................      16.0355      15.9476      18.9951      16.9629
370177......................................................      11.8757      11.2536      14.6481      12.5743
370178......................................................      11.6384      10.5726      11.6200      11.2422
370179......................................................      19.2677      17.2829      21.3002      18.9651
370183......................................................       7.6164      10.2945      16.9318      11.0088
370186......................................................      13.3454      13.6192      15.4533      14.1321
370190......................................................      13.7032      14.1397      19.3570      15.3737
370192......................................................      16.7402      18.4614      19.6967      18.2866
370197......................................................      21.5718            *            *      21.5718
370198......................................................            *      21.3136            *      21.3136
370200......................................................            *            *      22.5299      22.5299
380001......................................................      22.0255      20.3127      26.4822      22.5494
380002......................................................      19.4764      24.0241      21.9185      21.9840
380003......................................................      24.7434      21.7826      20.9007      22.2865
380004......................................................      23.1432      23.1451      23.3609      23.2208
380005......................................................      23.2415      24.0838      25.0750      24.1485
380006......................................................      20.5375      21.2731      21.3520      21.0653
380007......................................................      24.2933      25.2995      32.2678      27.0282
380008......................................................      21.1888      20.7063      22.3004      21.4082
380009......................................................      25.1702      23.8104      24.3851      24.4234
380010......................................................      19.7477      23.7488      22.7276      21.8451
380011......................................................      21.1353      21.1151      20.3357      20.8683
380013......................................................      20.1038      18.6818      19.8180      19.5721
380014......................................................      23.4819      24.6574      25.9828      24.7413
380017......................................................      23.8231      26.0578      25.3954      25.0552
380018......................................................      22.0776      22.3525      22.9822      22.4971
380019......................................................      20.7700      22.1215      20.8176      21.2209
380020......................................................      21.3556      20.1464      22.9568      21.5448
380021......................................................      20.6358      21.1590      23.8499      21.8371

[[Page 40014]]

 
380022......................................................      21.6110      22.6408      24.5974      22.8841
380023......................................................      19.2357      20.5462      21.3831      20.3976
380025......................................................      24.6738      26.3652      26.9346      25.9824
380026......................................................      19.2663      20.4706      20.6972      20.1525
380027......................................................      20.1576      20.8647      21.5490      20.8958
380029......................................................      18.5699      19.4246      20.1471      19.4015
380031......................................................      22.8346      23.3181      20.3396      22.1492
380033......................................................      23.2881      25.2454      27.1343      25.1500
380035......................................................      21.6533      22.4099      23.9719      22.6232
380036......................................................      19.3269      27.1587      27.2157      23.8613
380037......................................................      21.2347      21.9158      22.1774      21.7911
380038......................................................      25.5750      26.0869      26.7759      26.1419
380039......................................................      22.1235      23.1746      22.8048      22.6937
380040......................................................      21.6378      26.2717      22.5477      23.4095
380042......................................................      19.8096      21.1176      24.4172      21.7244
380047......................................................      21.9511      23.0718      24.2524      23.1258
380048......................................................      18.3847      17.5885      18.3005      18.0671
380050......................................................      18.2486      20.3934      20.3205      19.6254
380051......................................................      21.2358      22.3568      22.3207      21.9927
380052......................................................      17.8741      19.4570      18.6299      18.6300
380055......................................................      21.2459            *            *      21.2459
380056......................................................      17.1600      19.5185      18.4961      18.3892
380060......................................................      23.2923      24.2670      24.2059      23.9182
380061......................................................      22.5983      22.3736      22.8781      22.6217
380062......................................................      18.5229      20.7716      18.2148      19.1910
380063......................................................      19.3566      20.4077            *      19.9113
380064......................................................      19.8719      19.9826      22.9160      20.8404
380065......................................................      22.1706      26.1404      22.9608      23.6770
380066......................................................      20.4189      22.0349      23.2794      21.9793
380068......................................................      22.7573      22.3178            *      22.5559
380069......................................................      19.5793      19.8300      20.4882      19.9809
380070......................................................      24.7116      27.2541      27.7790      26.6130
380071......................................................      20.4707      22.6386      25.1808      22.8743
380072......................................................      16.3169      19.1553      19.4346      18.3236
380075......................................................      22.1703      22.3625      22.4139      22.3203
380078......................................................      19.1035      20.2507      21.0903      20.1439
380081......................................................      20.5902      20.9882      20.4082      20.6790
380082......................................................      22.5856      22.2275      22.9606      22.5990
380083......................................................      21.8096      21.3859      21.7431      21.6440
380084......................................................      23.6412      24.2844      27.1689      24.9815
380087......................................................      14.0976      16.5309      17.0380      15.8783
380088......................................................      19.5204      21.5225      19.5346      20.1728
380089......................................................      23.7413      19.5255      25.2908      23.0572
380090......................................................      27.0867      29.2702      24.9351      26.9453
380091......................................................      22.8333      27.5560      25.3062      25.1774
390001......................................................      18.6384      19.2989      19.6732      19.2277
390002......................................................      18.0787      21.8353      19.7833      19.8184
390003......................................................      17.2435      17.1371      18.1025      17.4798
390004......................................................      18.8899      19.2277      20.3204      19.4755
390005......................................................      16.4459      17.3506      16.9472      16.9256
390006......................................................      19.6012      20.2959      21.1786      20.3254
390007......................................................      21.4093      21.7506      21.3839      21.5152
390008......................................................      16.7440      17.8297      18.2743      17.6097
390009......................................................      20.1181      20.6507      20.6241      20.4567
390010......................................................      17.2315      17.5127      17.3335      17.3583
390011......................................................      18.0683      18.1717      18.3257      18.1941
390012......................................................      20.0227      20.6523      21.0610      20.5672
390013......................................................      19.3300      19.2698      19.6562      19.4200
390015......................................................      12.9372      13.1337      13.7352      13.2647
390016......................................................      17.0679      16.9892      17.1133      17.0565
390017......................................................      16.2170      16.7493      18.6113      17.1752
390018......................................................      19.1241      21.3626      19.0279      19.8558
390019......................................................      16.3965      16.7848      17.7258      16.9784

[[Page 40015]]

 
390022......................................................      22.8967      21.5064      24.8468      23.0587
390023......................................................      19.5639      21.8270      22.1044      21.4167
390024......................................................      25.0359      24.9437      25.4606      25.1433
390025......................................................      15.7111      15.6155      15.5523      15.6287
390026......................................................      22.7645      22.3902      22.9718      22.7143
390027......................................................      27.6893      26.8878      29.5940      28.0411
390028......................................................      20.1087      22.7700      23.6571      22.0510
390029......................................................      19.6883      21.5729      21.2661      20.8012
390030......................................................      18.3978      17.9580      18.6887      18.3432
390031......................................................      19.5175      19.2755      18.8162      19.2068
390032......................................................      18.1492      17.8041      21.5105      19.0439
390035......................................................      18.5146      20.2029      22.3591      20.2740
390036......................................................      18.8657      19.9880      19.7671      19.5278
390037......................................................      22.2359      21.0616      20.4263      21.2243
390039......................................................      16.5438      17.1046      17.5300      17.0475
390040......................................................      15.1211      15.9612      16.6876      15.9078
390041......................................................      19.5760      19.8080      20.4397      19.9243
390042......................................................      21.1276      22.7693      22.5775      22.1662
390043......................................................      16.3561      17.2607      17.4764      17.0230
390044......................................................      19.5419      20.2813      20.9831      20.2788
390045......................................................      18.4591      18.5574      19.4677      18.8305
390046......................................................      20.4608      20.7303      21.7445      20.9727
390047......................................................      24.5824      27.6661      26.9709      26.2900
390048......................................................      18.3801      19.0920      19.7992      19.0527
390049......................................................      21.1318      21.1217      22.1586      21.4802
390050......................................................      20.9240      22.8808      22.2639      22.0253
390051......................................................      26.0485      25.7910      28.1385      26.5675
390052......................................................      17.0988      20.9306      20.1195      19.3733
390054......................................................      17.4382      17.8852      18.4975      17.9431
390055......................................................      25.8961      24.2211      23.4017      24.4911
390056......................................................      17.1692      17.7858      19.3901      18.0977
390057......................................................      19.7459      20.2059      20.2395      20.0600
390058......................................................      19.2543      19.7379      20.3520      19.7916
390060......................................................      13.6276            *            *      13.6276
390061......................................................      20.4819      21.2392      23.8722      21.8310
390062......................................................      16.4505      16.6721      17.3750      16.8291
390063......................................................      19.6373      20.0125      19.4965      19.7211
390065......................................................      20.0001      19.9361      20.0473      19.9948
390066......................................................      18.7064      19.8539      18.9296      19.1567
390067......................................................      20.6515      20.9688      20.8162      20.8116
390068......................................................      17.5524      18.3158      19.1109      18.3267
390069......................................................      19.2858      19.6466            *      19.4555
390070......................................................      20.1862      16.1988      21.8549      19.3957
390071......................................................      16.2298      15.7165      16.0100      15.9856
390072......................................................      15.5565      16.3133      16.9232      16.2264
390073......................................................      20.6859      20.5581      21.2623      20.8422
390074......................................................      16.5971      18.4806      18.3093      17.7465
390075......................................................      17.2676      17.9840      18.7695      17.9105
390076......................................................      21.4307      20.2475      21.3290      20.9889
390078......................................................      18.2328      19.2089      19.0156      18.8052
390079......................................................      18.1969      18.3312      18.9269      18.4731
390080......................................................      19.5180      18.8028      21.4707      19.8661
390081......................................................      23.9922      24.8351      24.7461      24.5194
390083......................................................      20.5919            *            *      20.5919
390084......................................................      16.3463      16.4026      20.2529      17.4556
390086......................................................      17.2481      18.5265      18.3563      18.0522
390088......................................................      23.4941      23.6173      23.9506      23.6668
390090......................................................      20.6463      21.6437      21.3759      21.2068
390091......................................................      18.3746      18.1569      18.3770      18.3019
390093......................................................      16.6336      17.7171      18.4442      17.6019
390095......................................................      13.0459      16.3357      16.6930      15.2335
390096......................................................      19.3118      19.1171      22.4382      20.4516
390097......................................................      21.4115      23.5963      25.2845      23.2449

[[Page 40016]]

 
390100......................................................      20.3014      20.7859      20.9263      20.6729
390101......................................................      17.0534      17.9499      18.5039      17.8169
390102......................................................      19.4924      19.0461      21.5496      20.0293
390103......................................................      17.7054      18.4312      18.8667      18.3176
390104......................................................      15.9605      15.9008      16.3255      16.0548
390106......................................................      16.2783      16.6666      16.8439      16.6044
390107......................................................      19.1793      19.5178      20.9841      19.9123
390108......................................................      21.2872      21.0899      21.3142      21.2288
390109......................................................      14.6645      16.4597      16.5299      15.8639
390110......................................................      21.3191      21.5282      21.6464      21.5043
390111......................................................      28.7875      27.5193      33.3971      29.8383
390112......................................................      14.0439      14.9427      15.0065      14.6808
390113......................................................      17.9377      19.1945      19.3634      18.8262
390114......................................................      22.9698      19.6295      20.9533      21.1250
390115......................................................      24.7244      23.3461      21.4287      23.0792
390116......................................................      20.6016      21.4877      21.3671      21.1457
390117......................................................      16.9036      17.9393      18.0769      17.6425
390118......................................................      16.8962      18.3440      18.9507      18.0638
390119......................................................      18.5935      18.2951      18.8815      18.5863
390121......................................................      18.6422      20.8780      19.1315      19.5644
390122......................................................      17.4645      17.1902      17.7734      17.4764
390123......................................................      20.8412      20.8344      21.3974      21.0254
390125......................................................      15.9356      16.7983      17.5446      16.7393
390126......................................................      20.9383      20.6498            *      20.8020
390127......................................................      21.8849      21.7724      22.4555      22.0398
390128......................................................      19.4132      19.6792      19.3165      19.4699
390130......................................................      17.3253      17.7049      18.3695      17.7936
390131......................................................      16.8349      16.0986      19.2096      17.3202
390132......................................................      20.5528      21.1931      22.8414      21.4849
390133......................................................      24.6131      23.3489      24.7561      24.1960
390135......................................................      21.2497      21.5782      22.1905      21.6491
390136......................................................      17.6128      16.9737      20.6286      18.3801
390137......................................................      16.5598      17.5687      18.5397      17.5480
390138......................................................      18.8601      19.6212      20.6936      19.7394
390139......................................................      22.9351      24.4515      23.9757      23.7712
390142......................................................      26.7954      26.8086      28.8877      27.5656
390145......................................................      20.3393      20.3731      20.4228      20.3787
390146......................................................      17.7020      18.7922      18.6505      18.3503
390147......................................................      21.1085      20.9651      21.2492      21.1067
390150......................................................      19.6575      20.7294      20.3155      20.2474
390151......................................................      20.5084      21.6000      22.5206      21.5535
390152......................................................      19.1525      20.3353      19.4017      19.6203
390153......................................................      23.1183      23.7013      22.9707      23.2621
390154......................................................      15.8478      17.4036      16.7052      16.6538
390156......................................................      21.1629      21.8498      22.6398      21.8660
390157......................................................      19.8268      19.6578      19.1783      19.5633
390158......................................................      21.6045            *            *      21.6045
390160......................................................      20.7676      21.4810      19.4463      20.4967
390161......................................................      12.3743      16.4799            *      14.3389
390162......................................................      21.0228      21.4095      21.9188      21.4386
390163......................................................      15.6227      16.8013      17.7564      16.7297
390164......................................................      21.5890      24.6765      24.9750      23.5327
390166......................................................      19.9612      19.0405      19.7978      19.5957
390167......................................................      22.9136      19.8973            *      21.3982
390168......................................................      18.9936      18.7400      18.8863      18.8736
390169......................................................      18.9878      20.2382      22.0547      20.4487
390170......................................................      22.9877      26.5891      24.7973      24.6450
390173......................................................      17.8568      18.5370      18.6613      18.3502
390174......................................................      25.2407      25.4189      25.3307      25.3310
390176......................................................      17.3577      17.8740      20.8368      18.6587
390178......................................................      17.7036      16.6993      17.0534      17.1490
390179......................................................      21.4093      21.6901      21.8593      21.6579
390180......................................................      25.1191      25.7074      26.5541      25.8271

[[Page 40017]]

 
390181......................................................      17.0860      19.4654      19.3832      18.6237
390183......................................................      19.0834      17.8306      17.9848      18.2942
390184......................................................      20.7489      20.8060      20.9349      20.8256
390185......................................................      17.6516      18.8798      20.3877      18.9752
390189......................................................      18.6668      20.0889      20.3338      19.6907
390191......................................................      16.1993      16.3240      17.2270      16.5760
390192......................................................      16.3696      17.4537      17.6597      17.1476
390193......................................................      16.4663      16.7874      18.1209      17.0634
390194......................................................      20.1547      20.7953      21.2689      20.7092
390195......................................................      23.6920      24.6855      24.1793      24.1876
390197......................................................      18.9857      19.2690      20.7998      19.6927
390198......................................................      15.4508      15.9721      15.8833      15.7671
390199......................................................      16.6644      17.0515      17.3865      17.0306
390200......................................................      13.5898      15.1399      15.4012      14.7971
390201......................................................      20.5011      20.6296      20.3533      20.4916
390203......................................................      21.1895      20.9432      21.4989      21.2088
390204......................................................      20.8483      20.1779      22.9616      21.3067
390206......................................................      18.5746      18.4027            *      18.4910
390209......................................................      16.9558      17.4792      18.7059      17.7155
390211......................................................      17.9132      17.8638      18.4213      18.0846
390213......................................................      17.4453      18.8555      19.1553      18.5312
390215......................................................      21.4291      20.7084      21.2032      21.1048
390217......................................................      19.2926      19.1406      19.9837      19.4647
390219......................................................      21.6295      18.8292      19.6226      19.9600
390220......................................................      18.5178      18.7178      17.7916      18.3301
390222......................................................      20.9080      21.5739      22.1548      21.5483
390223......................................................      22.6498      23.6482      22.1775      22.7892
390224......................................................      15.9058      15.3015      13.7518      14.9518
390225......................................................      18.1752      18.6125      18.7290      18.5053
390226......................................................      23.1638      21.8268      21.8481      22.2835
390228......................................................      19.8129      19.4083      19.8180      19.6802
390231......................................................      24.4852      22.7544      19.4798      21.9903
390233......................................................      18.7707      19.4887      20.2309      19.5042
390235......................................................      24.6044      25.0857      21.4200      24.0078
390236......................................................      17.0339      16.2397      17.8735      17.0494
390237......................................................      21.7479      19.5230      22.3011      21.1430
390238......................................................            *      17.8211      17.1055      17.4821
390242......................................................      18.0943            *            *      18.0943
390244......................................................      14.4133      15.4611      15.6402      15.1810
390245......................................................      20.1544      26.0194      24.5076      23.4886
390246......................................................      17.9214      18.9733      25.0556      20.2904
390247......................................................      20.6671      20.9526      21.2151      20.8919
390249......................................................      10.7336      12.7920      13.1657      12.2298
390256......................................................      23.7828      20.9469      22.2773      22.2601
390258......................................................      21.3629      21.9207      22.6852      21.9998
390260......................................................      21.1917      21.9509      21.5982      21.5728
390262......................................................      18.6684      18.2379            *      18.4504
390263......................................................      20.0939      20.6855      20.3796      20.3890
390265......................................................      19.5089      20.3580      20.4950      20.1207
390266......................................................      16.2372      17.1666      17.1966      16.8552
390267......................................................      20.5125      21.2974      19.2665      20.4773
390268......................................................      21.0161      21.3486      22.0909      21.4791
390270......................................................      17.8280      19.0925      19.2074      18.7055
390277......................................................      27.0983            *            *      27.0983
390278......................................................      19.2019      18.2865      17.7176      18.4620
390279......................................................      13.6992      14.3241      14.8655      14.2998
390283......................................................            *            *      22.5490      22.5490
390284......................................................            *            *      34.3904      34.3904
400001......................................................       9.8615       9.9463      10.5757      10.1359
400002......................................................       9.3063      10.1417      13.0494      10.8249
400003......................................................       9.9865      10.8821      12.4078      11.0633
400004......................................................       8.4811       8.9864       8.5648       8.6695
400005......................................................       7.8494       9.5632       7.7432       8.3858

[[Page 40018]]

 
400006......................................................      10.5281      10.3444      10.1048      10.3288
400007......................................................       7.8637       6.4490       8.0174       7.3754
400009......................................................       8.3727       8.4207       8.8650       8.5497
400010......................................................      11.6642      10.6518      10.8011      10.9779
400011......................................................       5.6825       7.4979       8.5426       7.2512
400012......................................................       7.8134       8.2412       8.4728       8.1883
400013......................................................       8.2066       8.4579       9.2624       8.6839
400014......................................................       9.5354       9.5235       9.4798       9.5126
400015......................................................      10.3326      10.9505      14.4076      11.3577
400016......................................................      12.0743      13.2756      13.3922      12.9125
400017......................................................       8.5675       8.6421       9.2577       8.8024
400018......................................................       9.4534      10.4557      10.6208      10.1978
400019......................................................      10.1512      10.4332      10.8940      10.5307
400021......................................................       9.9121      10.6988      12.1434      10.9538
400022......................................................      11.1204      11.5861      12.2199      11.6336
400024......................................................       7.5594       7.8984       9.2409       8.1615
400026......................................................       7.1236       5.6454       5.8335       6.1312
400027......................................................       8.4862       9.5899            *       9.0120
400028......................................................       8.3991       8.8597       9.1794       8.7817
400031......................................................       9.7826       8.2660            *       8.9857
400032......................................................       9.7291      10.5498      10.0448      10.1074
400044......................................................      11.7484      11.9704      11.9486      11.8844
400048......................................................       8.9224       9.1701      15.1405      10.3604
400061......................................................      12.2770      12.4493      13.0988      12.5813
400079......................................................       7.0830            *       9.7203       8.1082
400087......................................................      10.3972       9.5097       9.8534       9.8687
400094......................................................       7.8208       8.9116       7.9187       8.1829
400098......................................................       7.2098       9.3308       9.7791       8.8630
400102......................................................       7.7288       9.8536       9.9903       9.1668
400103......................................................      10.7316      11.2069      11.5359      11.1167
400104......................................................       9.9416      11.0672      10.7292      10.5214
400105......................................................      10.1726       9.3049       9.0556       9.5335
400106......................................................       8.5143       9.3123       9.2187       9.0108
400109......................................................      10.1786      10.9826      11.8760      11.0486
400110......................................................      10.5250      10.3326      10.5277      10.4760
400111......................................................       9.5600       9.5583      10.9665      10.1021
400112......................................................      12.8478      10.1755      10.8694      11.2941
400113......................................................       9.4835       9.2238       8.3168       9.0068
400114......................................................       6.4076       9.0496       7.0510       7.4630
400115......................................................       9.1311       9.8244       8.5487       9.1780
400117......................................................      10.0381      10.2295      10.8756      10.3823
400118......................................................       8.6964       9.4398      11.4051       9.9004
400120......................................................       9.7425       9.5274      10.6584       9.9956
400121......................................................       7.1061       7.8052       9.8322       8.2686
400122......................................................       8.4806       8.1911       7.6413       8.0571
400123......................................................       9.0217       7.8099      10.2367       9.0130
400124......................................................      11.4839      12.0999      12.2452      11.9729
400125......................................................            *            *      10.2056      10.2056
410001......................................................      22.5322      23.2808      23.1738      23.0006
410004......................................................      22.3212      22.4801      21.0638      22.0103
410005......................................................      21.2407      23.1444      22.7170      22.3365
410006......................................................      21.9798      23.3968      23.8700      23.0621
410007......................................................      20.9489      22.1452      23.1325      22.1106
410008......................................................      22.6133      23.0662      24.9726      23.5244
410009......................................................      24.0769      24.4899      24.3895      24.3200
410010......................................................      27.1426      26.9813      28.4589      27.5328
410011......................................................      24.3676      25.2926      26.1183      25.2512
410012......................................................      21.3337      24.5811      24.1695      23.4018
410013......................................................      25.0050      24.5122      24.8800      24.7951
420002......................................................      20.2049      19.4845      20.7804      20.1513
420004......................................................      19.4079      19.7968      20.9588      20.0732
420005......................................................      15.9906      17.3510      17.9694      17.1171
420006......................................................      18.2374      18.3439      19.1760      18.5687

[[Page 40019]]

 
420007......................................................      17.5783      18.2096      18.6456      18.1319
420009......................................................      17.2515      18.5456      19.9586      18.6114
420010......................................................      17.9141      17.1184      18.0252      17.6914
420011......................................................      14.9944      16.5664      18.0970      16.4913
420014......................................................      16.7219      16.6065      18.0519      17.0894
420015......................................................      17.1802      18.8411      20.1164      18.5841
420016......................................................      18.1451      15.6241      15.5485      16.2939
420018......................................................      19.7285      19.7367      21.8775      20.3791
420019......................................................      15.5521      16.9990      17.1726      16.5419
420020......................................................      17.9011      20.9449      20.3193      19.6942
420023......................................................      20.9663      19.4855      20.4053      20.2598
420026......................................................      21.8968      20.3476      21.8749      21.3678
420027......................................................      18.0774      18.8457      19.2594      18.7307
420029......................................................      18.3557            *            *      18.3557
420030......................................................      17.8215      19.1453      20.6448      19.3038
420031......................................................      13.0718      14.1855       8.2516      11.1227
420033......................................................      21.0863      21.7279      23.1303      21.9705
420036......................................................      19.7421      17.6136      21.3222      19.4565
420037......................................................      21.9603      21.7908      22.7099      22.1669
420038......................................................      16.1498      17.6726      18.6568      17.4393
420039......................................................      16.9646      15.8385      18.3017      17.0260
420042......................................................      14.6567            *            *      14.6567
420043......................................................      18.3607      19.4521      19.7570      19.1785
420048......................................................      18.0286      18.4367      18.8070      18.4223
420049......................................................      19.2340      17.5854      19.4049      18.7208
420051......................................................      18.2518      19.5001      19.1555      18.9941
420053......................................................      16.5452      16.9599      18.1657      17.1887
420054......................................................      16.5474      18.2702      20.2574      18.3229
420055......................................................      16.1823      19.2048      16.8717      17.3777
420056......................................................      15.5966      14.8695      15.1835      15.1636
420057......................................................      14.5006      15.9849      20.5266      17.2252
420059......................................................      19.1303      15.8160      17.1483      17.3325
420061......................................................      16.1310      16.5555      17.3543      16.6881
420062......................................................      18.9513      17.8205      21.7469      19.4924
420064......................................................      15.4531      16.7227      16.0794      16.0985
420065......................................................      19.0645      19.6902      19.9435      19.5673
420066......................................................      15.5001      15.1804      18.0042      16.2261
420067......................................................      18.3106      18.8610      19.7824      19.0239
420068......................................................      17.2144      18.5030      18.5481      18.0958
420069......................................................      16.3189      17.0788      18.1298      17.2134
420070......................................................      17.4486      18.0057      17.3876      17.6174
420071......................................................      18.2878      19.4482      20.3902      19.3836
420072......................................................      12.6013      13.8550      15.0158      13.8117
420073......................................................      19.2011      19.1604      19.9986      19.4566
420074......................................................      13.8038      16.9292      18.0967      16.2019
420075......................................................      16.2946      14.2931      12.8158      14.3372
420078......................................................      20.6818      20.7317      21.9082      21.1259
420079......................................................      18.7710      20.8639      21.0874      20.2636
420080......................................................      24.8321      22.3443      21.9968      22.9897
420081......................................................      20.4211            *            *      20.4211
420082......................................................      18.8848      20.4653      21.7210      20.3535
420083......................................................      23.3425      20.1472      22.6376      21.9902
420085......................................................      18.5502      19.9603      21.6791      20.1188
420086......................................................      19.3054      25.7179      20.2878      21.4636
420087......................................................      18.4016      19.1403      19.8388      19.1412
420088......................................................      17.9063      17.1938      19.9919      18.3046
420089......................................................      21.6608      20.2537      20.5360      20.7623
420091......................................................      18.5723      18.8687      20.3092      19.2195
420093......................................................      16.7734      17.4689      18.3902      17.5654
420094......................................................      32.6768            *            *      32.6768
430004......................................................      17.8435      18.5438      19.6344      18.6310
430005......................................................      15.8449      16.3059      16.4560      16.2068
430007......................................................      14.0586      14.1078      14.6331      14.2620

[[Page 40020]]

 
430008......................................................      16.7640      17.6640      18.1323      17.5240
430010......................................................      16.1093      17.1766      19.8191      17.5891
430011......................................................      16.4234      16.9848      17.4750      16.9703
430012......................................................      17.7809      17.2775      17.6997      17.5855
430013......................................................      17.2424      18.1338      18.4817      17.9391
430014......................................................      18.4417      16.8925      20.2387      18.3922
430015......................................................      16.4123      18.0019      18.2875      17.5236
430016......................................................      18.9715      19.4759      20.8850      19.7559
430018......................................................      14.9100      14.8854      16.2244      15.3323
430022......................................................      12.9532      13.4905      14.5118      13.6222
430023......................................................      11.6383      12.2331      16.2164      13.2302
430024......................................................      13.9942      15.4709      16.1801      15.3449
430026......................................................      10.8532            *            *      10.8532
430027......................................................      18.6367      19.1461      20.2591      19.2968
430028......................................................      16.7185      18.2312      17.1577      17.3522
430029......................................................      15.1010      16.6500      17.6986      16.5066
430031......................................................      12.4631      13.1258      12.4660      12.6792
430033......................................................      14.6423      15.3003      17.3652      15.6688
430034......................................................      12.8513      15.4064      14.2491      14.1740
430036......................................................      13.7807      13.6967      15.6258      14.3461
430037......................................................      15.9545      16.5368      18.1293      16.8632
430038......................................................      11.9419      13.7167      18.4078      14.2118
430040......................................................      13.3722      13.6745      14.4509      13.8057
430041......................................................      12.6235      13.1936      14.8816      13.4964
430043......................................................      13.4288      13.6908      14.9949      14.0204
430044......................................................      16.4488      18.4970      21.0823      18.5195
430047......................................................      15.6227      17.4956      17.9823      16.9377
430048......................................................      17.2589      18.3524      18.7602      18.0996
430049......................................................      14.4354      15.5381      15.2237      15.0640
430051......................................................      17.2139      17.0574      18.8070      17.6987
430054......................................................      13.5011      14.7251      14.8003      14.3524
430056......................................................      11.4117      11.7627      10.3697      11.1792
430057......................................................      15.1516      15.4390      17.2805      15.9601
430060......................................................       8.6409       9.0358      10.0176       9.2343
430062......................................................      10.8879            *            *      10.8879
430064......................................................      12.7394      14.4367      14.2184      13.7779
430065......................................................      12.7660            *            *      12.7660
430066......................................................      13.4380      14.3557      15.6660      14.4524
430073......................................................      14.9784      16.1133      15.3776      15.4839
430076......................................................      12.2452      12.7608      13.9883      12.9521
430077......................................................      17.7126      19.3012      19.8558      18.9586
430079......................................................      12.9780      13.6836      14.1815      13.5924
430087......................................................      10.4491            *            *      10.4491
430089......................................................      17.0065      17.8908      17.9790      17.6658
430090......................................................            *      21.5239      21.5974      21.5592
430091......................................................            *      19.2146      18.1567      18.5152
430092......................................................            *            *      21.3807      21.3807
430093......................................................            *            *      19.5013      19.5013
440001......................................................      15.3134      14.8713      15.5897      15.2550
440002......................................................      18.5411      19.1498      20.3740      19.3756
440003......................................................      17.4736      18.3658      19.3042      18.3967
440006......................................................      20.6559      19.6021      21.4055      20.5221
440007......................................................       7.7632      12.1230      14.8959      11.0241
440008......................................................      15.4701      17.2848      18.8994      17.1822
440009......................................................      15.4558      17.8424      17.4831      16.9676
440010......................................................      13.5118      19.9829      16.3283      16.4644
440011......................................................      17.1591      17.6948      18.3375      17.7161
440012......................................................      19.0606      15.9837      19.5739      18.2503
440014......................................................      14.6093      15.9195      16.1143      15.5705
440015......................................................      21.0884      18.2632      22.0659      20.4116
440016......................................................      14.9409      15.4097      16.2964      15.5583
440017......................................................      21.1258      19.6215      20.4563      20.3835
440018......................................................      18.2080      16.4115      17.4995      17.3550

[[Page 40021]]

 
440019......................................................      28.2242      20.0416      21.5402      22.7883
440020......................................................      15.5889      18.1154      17.8879      17.2181
440022......................................................      19.0214      15.8459            *      17.5909
440023......................................................      14.1410      15.4721      16.7837      15.4038
440024......................................................      18.1028      18.4432      18.4046      18.3183
440025......................................................      15.2826      15.8784      16.3140      15.8395
440026......................................................      22.9174      23.0550      23.2566      23.0549
440029......................................................      18.5183      19.4326      20.7050      19.5797
440030......................................................      15.5718      16.2941      16.9925      16.3267
440031......................................................      14.3023      15.5432      17.0211      15.6197
440032......................................................      13.5996      13.9775      13.8140      13.7931
440033......................................................      14.0409      14.5304      13.7328      14.1227
440034......................................................      17.9315      19.5470      20.0309      19.2030
440035......................................................      18.1578      18.9026      19.3034      18.7862
440039......................................................      19.3747      19.9439      21.6536      20.3424
440040......................................................      17.4965      16.3740      16.9275      16.9214
440041......................................................      13.6279      14.6621      14.9545      14.4249
440046......................................................      16.8798      18.1654      19.3229      18.0984
440047......................................................      17.0037      16.6646      17.8092      17.1528
440048......................................................      18.1449      19.4498      21.4993      19.5981
440049......................................................      16.7066      17.9292      18.7967      17.8439
440050......................................................      16.7627      19.1328      18.2511      18.0098
440051......................................................      14.9074      13.1901      16.0421      14.6532
440052......................................................      16.2693      16.6541      19.8075      17.4207
440053......................................................      17.6873      18.5515      19.6494      18.6583
440054......................................................      12.3134      13.8716      13.3967      13.1942
440056......................................................      14.2534      15.9821      16.2742      15.4778
440057......................................................      12.7190      12.7925      13.7257      13.0446
440058......................................................      18.7381      18.8118      19.1878      18.9185
440059......................................................      17.5274      18.5418      19.6018      18.6049
440060......................................................      15.8599      18.0586      19.7916      17.7309
440061......................................................      16.8442      14.9708      22.5525      17.8114
440063......................................................      18.2923      19.3222      19.8371      19.1661
440064......................................................      17.6154      17.7652      18.9809      18.1133
440065......................................................      18.6943      18.5825      18.8296      18.7013
440067......................................................      22.0655      16.2811      17.2397      18.2348
440068......................................................      17.4513      19.4695      19.3668      18.7087
440070......................................................      15.0440      13.7035      14.0437      14.2715
440071......................................................      16.2691      17.0186      19.7836      17.5412
440072......................................................      16.7675      17.5995      19.1522      17.8026
440073......................................................      18.5576      19.1714      19.5554      19.1079
440078......................................................      13.0916      15.0849      16.0188      14.6728
440081......................................................      17.9702      18.3587      19.3454      18.5764
440082......................................................      23.0805      22.2857      22.6855      22.6613
440083......................................................      35.0978      14.8525      13.7423      17.4998
440084......................................................      13.3678      13.4378      13.7731      13.5305
440091......................................................      19.7250      19.6114      20.1065      19.8343
440100......................................................      13.9487      13.8437      14.7113      14.1637
440102......................................................      13.9575      14.3510      14.5500      14.2949
440103......................................................      19.2083      20.3052      18.6990      19.3857
440104......................................................      22.3883      22.4403      22.6754      22.4883
440105......................................................      16.0338      16.7131      17.1172      16.6050
440109......................................................      14.2491      16.0446      17.7443      15.8919
440110......................................................      15.9174      21.1716      17.4816      17.9016
440111......................................................      21.0682      23.2425      23.2254      22.5309
440114......................................................      13.6095      14.4997      15.0036      14.3318
440115......................................................      12.9668      17.4514      18.5457      16.2205
440120......................................................      18.2993      17.2384      16.3115      17.2831
440125......................................................      16.1067      15.6588      19.4115      17.0424
440130......................................................      16.6750      17.8223      17.4857      17.3264
440131......................................................      14.6752      15.5048      16.1214      15.4186
440132......................................................      15.9069      16.6553      16.8871      16.4950
440133......................................................      21.5116      21.5313      23.0891      22.0182

[[Page 40022]]

 
440135......................................................      20.9029      19.2010      22.2005      20.8180
440137......................................................      14.6966      14.5632      15.0070      14.7511
440141......................................................      12.4774      13.5308      15.9429      13.7977
440142......................................................      13.0059      15.7287      16.8855      15.0859
440143......................................................      17.8429      17.7821      18.2061      17.9416
440144......................................................      16.6666      17.6415      18.3859      17.5674
440145......................................................      13.6577      17.0608      18.3948      16.1716
440147......................................................      22.0069      21.4304      26.1464      23.0399
440148......................................................      17.6438      19.2435      19.4598      18.7842
440149......................................................      17.1496      16.6923      18.4281      17.4374
440150......................................................      13.0775      20.1411      20.3006      17.2935
440151......................................................      15.4250      17.4248      18.3928      17.0781
440152......................................................      17.8399      21.0287      22.7664      20.2196
440153......................................................      16.0954      16.7769      16.5716      16.4916
440156......................................................      19.6117      29.5557      21.7577      23.1575
440157......................................................      11.3982      16.9265      18.4249      15.5384
440159......................................................      17.6237      17.7158      20.9371      18.4872
440161......................................................      20.7643      21.8013      22.8816      21.7855
440162......................................................      14.4121      14.7637      15.5534      14.8623
440166......................................................      18.1413      19.6684      19.2159      18.9985
440168......................................................      15.9513      18.6535      19.1509      17.9995
440173......................................................      18.4683      18.6402      19.1812      18.7699
440174......................................................      17.0080      17.3294      18.0865      17.4583
440175......................................................      17.6107      20.0802      18.5186      18.7356
440176......................................................      18.7529      18.0294      19.2208      18.6470
440180......................................................      17.3412      19.7773      20.2184      19.1376
440181......................................................      11.8471      16.4878      17.7709      15.0662
440182......................................................      20.3202      17.7487      19.7094      19.1341
440183......................................................      19.4374      22.7067      21.3465      21.1277
440184......................................................      18.0603      17.2037      16.8880      17.4646
440185......................................................      18.7286      19.3870      21.2188      19.7784
440186......................................................      18.5312      19.3948      19.7983      19.2465
440187......................................................      16.2530      18.9713      17.5872      17.6013
440189......................................................      16.1906            *      18.5252      17.4309
440192......................................................      19.9669      19.0839      19.1705      19.3968
440193......................................................      18.3952      19.0811      18.6999      18.7380
440194......................................................      20.3343      19.8682      22.4562      20.9277
440197......................................................      23.1080      21.9618      21.8503      22.2548
440200......................................................      16.0619      17.9575      19.8078      18.0280
440203......................................................      16.6132      18.3400      16.2861      17.0710
440206......................................................      15.5462      16.4429            *      16.0270
440209......................................................      14.7466            *            *      14.7466
440210......................................................      12.3292      11.0218      11.9815      11.7402
440211......................................................            *      14.8972            *      14.8972
440212......................................................            *      17.0685            *      17.0685
440213......................................................            *      19.5760            *      19.5760
440214......................................................            *            *      28.0285      28.0285
440215......................................................            *            *      22.2928      22.2928
450002......................................................      19.9195      21.3749      21.4836      20.9147
450004......................................................      15.2751      16.6723      16.7850      16.2360
450005......................................................      15.5888      18.3600      16.6396      16.8103
450007......................................................      15.7536      16.9681      19.1910      17.3218
450008......................................................      15.7458      17.0832      17.6582      16.7901
450010......................................................      16.0790      16.5001      17.6677      17.0234
450011......................................................      18.0137      17.1942      20.8102      18.6782
450014......................................................      18.2173      17.9495      17.5815      17.9004
450015......................................................      18.4400      18.9895      21.6773      19.6131
450016......................................................      17.3054      18.4463      18.3456      18.0337
450018......................................................      20.4133      21.4788      23.2293      21.6061
450020......................................................      16.9661      17.8415      19.1153      18.0122
450021......................................................      22.6910      23.0843      23.3630      23.0474
450023......................................................      16.6408      16.0831      17.6360      16.7896
450024......................................................      16.5604      17.3518      18.5985      17.4846

[[Page 40023]]

 
450025......................................................      16.4396      17.0004            *      16.7280
450028......................................................      18.4287      18.8764      19.1658      18.8489
450029......................................................      17.6909      17.4716      17.7425      17.6360
450031......................................................      20.8992      22.2222      29.6945      23.8280
450032......................................................      15.2404      17.3317      14.6530      15.6504
450033......................................................      20.8634      19.7437      21.0222      20.5422
450034......................................................      18.9068      19.6721      18.8823      19.1560
450035......................................................      16.8132      20.0951      20.3599      19.0234
450037......................................................      18.6549      19.5411      19.9140      19.3829
450039......................................................      22.0811      19.8143      19.7176      20.5536
450040......................................................      17.5179      16.8534      19.6370      18.0669
450042......................................................      17.5906      19.8921      18.8357      18.7392
450044......................................................      21.0399      24.7961      21.0909      22.1921
450046......................................................      17.0917      18.6536      17.3631      17.6586
450047......................................................      13.9022      13.4486      16.9028      14.6102
450050......................................................      13.0037      14.7669      17.7209      15.0293
450051......................................................      20.0763      21.0236      21.1008      20.7301
450052......................................................      13.5278      13.8881      15.5890      14.3570
450053......................................................      17.3139      17.0467      17.2781      17.2160
450054......................................................      21.9835      22.8960      15.9388      20.5562
450055......................................................      14.8119      15.0433      15.8526      15.2415
450056......................................................      20.0008      21.8436      21.8605      21.2529
450058......................................................      16.9832      18.0967      18.6172      17.9075
450059......................................................      14.2072      15.2168      19.8240      16.2886
450063......................................................      13.8126      14.3815      12.7211      13.5914
450064......................................................      16.4165      17.4093      19.7682      17.8341
450065......................................................      19.6087      21.4934      23.3797      21.3723
450068......................................................      22.6924      22.8998      23.3495      22.9910
450072......................................................      17.3794      19.0111      18.0307      18.1442
450073......................................................      16.6168      17.1002      16.5942      16.7690
450078......................................................      13.4875      11.7265      13.2820      12.8188
450079......................................................      19.4899      21.0518      20.6483      20.4464
450080......................................................      16.3147      17.4553      18.6212      17.4805
450081......................................................      16.1653      16.3448      17.5737      16.7023
450082......................................................      13.2952      16.1585      16.8677      15.5279
450083......................................................      20.1830      21.5884      23.3754      21.7298
450085......................................................      14.2167      18.3602      20.0085      17.2728
450087......................................................      21.4764      22.0273      21.9320      21.8111
450090......................................................      13.9101      15.0939      15.5796      14.8590
450092......................................................      15.7316      16.8260      17.9520      16.8805
450094......................................................      19.4249      21.3158      23.2863      21.3961
450096......................................................      16.6300      17.8813      18.6802      17.7158
450097......................................................      18.2740      19.5723      19.7187      19.2252
450098......................................................      15.4796      20.5754      19.0454      18.3431
450099......................................................      22.8834      19.2258      20.4181      20.6312
450101......................................................      16.9628      17.1330      17.7928      17.2860
450102......................................................      18.8465      18.6707      19.8793      19.1269
450104......................................................      15.9781      16.6744      17.0821      16.5911
450107......................................................      20.7359      25.1986      24.1094      23.2223
450108......................................................      16.1451      15.6324      15.2797      15.6413
450109......................................................      12.7654      13.8127      10.5973      12.1326
450110......................................................      21.4421      19.5821            *      20.4354
450111......................................................      19.2749      19.6350      21.4908      20.1993
450112......................................................      14.7610      16.0441      18.1026      16.3114
450113......................................................      18.5356      20.9777      20.8306      19.9901
450118......................................................      15.8317      17.9053            *      16.9195
450119......................................................      18.3166      20.2853      20.2030      19.6520
450121......................................................      18.2278      20.4641      21.9198      20.1751
450123......................................................      19.1912      15.7618      14.1755      16.0237
450124......................................................      21.0925      22.7480      22.5208      22.1327
450126......................................................      17.4512      21.7233      21.4789      19.9557
450128......................................................      15.8881      18.2184      18.1446      17.4552
450130......................................................      17.8722      20.4156      18.9211      19.0565

[[Page 40024]]

 
450131......................................................      17.6163      19.2589      17.4168      18.0711
450132......................................................      18.0745      18.1713      21.8089      19.3784
450133......................................................      19.9259      23.6366      26.0763      23.0339
450135......................................................      20.8065      21.0306      20.4068      20.7284
450137......................................................      23.9555      22.4590      23.4346      23.2829
450140......................................................      18.0743      20.2280      17.3370      18.5682
450143......................................................      14.4623      14.5270      15.0871      14.7298
450144......................................................      16.3037      18.1121      17.4309      17.3356
450145......................................................      14.8441      15.6078      16.1895      15.5356
450146......................................................      14.2041      17.8572      15.5030      15.8115
450147......................................................      18.0664      18.9363      19.0477      18.6958
450148......................................................      22.0269      18.6758      20.4923      20.3406
450149......................................................      24.0005      19.7521      21.7219      21.7182
450150......................................................      15.2061      16.3719      17.8612      16.4235
450151......................................................      14.8373      15.2906      16.4209      15.5098
450152......................................................      17.3780      18.0061      17.7265      17.7015
450153......................................................      19.9447      19.4419      18.6514      19.3436
450154......................................................      13.1810      13.8731      13.9119      13.6623
450155......................................................      23.7678      11.5841      13.3456      14.7760
450157......................................................      14.6623      15.6371      15.3083      15.2158
450160......................................................       8.7503      16.6533      10.6852      11.1452
450162......................................................      22.1981      20.9560      21.9218      21.6852
450163......................................................      16.9811      17.5403      17.8028      17.4591
450164......................................................      20.0368      16.9741      17.7180      18.0843
450165......................................................      15.1561      13.9218      17.3283      15.3582
450166......................................................      10.2801      11.4772      11.0541      10.9545
450169......................................................      15.8793      13.1990            *      14.1674
450170......................................................      14.8131      14.2997      14.3234      14.4821
450176......................................................      16.3031      16.9674      17.2576      16.8653
450177......................................................      14.7280      14.9241      15.2419      14.9812
450178......................................................      16.7550      17.8508      16.0280      16.8828
450181......................................................      14.0192      15.5622      18.6936      16.1716
450184......................................................      19.9674      21.1263      20.0821      20.3949
450185......................................................      13.0632      14.0714      11.5228      12.7662
450187......................................................      17.5702      16.6945      18.5053      17.5863
450188......................................................      13.7757      14.3938      15.1954      14.4624
450191......................................................      18.8023      20.1222      20.9512      19.9757
450192......................................................      19.3352      20.3795      21.2497      20.3207
450193......................................................      22.7325      23.1963      23.1639      23.0345
450194......................................................      19.1466      20.5187      20.7745      20.1569
450196......................................................      16.4929      17.1955      17.8993      17.1933
450200......................................................      17.3756      18.7387      19.2228      18.4203
450201......................................................      17.0548      16.9908      17.1463      17.0668
450203......................................................      18.6552      20.6712      19.3978      19.6025
450209......................................................      18.6566      19.0811      20.0140      19.2218
450210......................................................      14.2317      13.9758      16.3470      14.7958
450211......................................................      17.1433      17.9857      18.8114      17.9863
450213......................................................      18.4472      17.7631      19.0651      18.4304
450214......................................................      17.2465      19.0475      20.5070      18.8579
450217......................................................      11.6893      12.8457      12.7647      12.4509
450219......................................................      15.4207      15.3976      17.6884      16.1962
450221......................................................      16.9935      16.3700      15.2120      16.1091
450222......................................................      18.4542      20.3129      19.8967      19.5439
450224......................................................      22.8300      24.9046      20.1579      22.3861
450229......................................................      16.4116      16.4503      16.7853      16.5551
450231......................................................      17.7045      19.1564      19.1746      18.9853
450234......................................................      13.3012      16.1945      16.3003      15.4055
450235......................................................      13.4177      15.2332      16.3115      15.0648
450236......................................................      15.6774      16.6703      16.4957      16.3054
450237......................................................      17.3984      20.7930      19.0325      19.0438
450239......................................................      13.6376      17.1308      17.8401      16.0311
450241......................................................      14.8674      12.5675      16.4240      14.4148
450243......................................................      12.3626      11.9099      13.6416      12.6485

[[Page 40025]]

 
450246......................................................      17.9702      16.5478      16.7959      17.0548
450249......................................................      11.6279      12.0302      11.7658      11.8055
450250......................................................      14.9133      10.2844      13.6787      12.3052
450253......................................................      15.3542      12.2402      13.2177      13.4392
450258......................................................      13.2334      16.0466      16.7337      15.4196
450259......................................................      17.8488            *            *      17.8488
450264......................................................      13.8879      13.8929      14.5956      14.1447
450269......................................................      14.9334      12.3594      12.7717      13.2360
450270......................................................      12.7018      12.8381      14.4792      13.2703
450271......................................................      15.4998      16.6319      16.7831      16.3572
450272......................................................      17.9514      19.9331      18.4344      18.7713
450276......................................................      12.7053      13.1155      14.0745      13.3159
450278......................................................      13.7894      14.8291      15.2950      14.5985
450280......................................................      19.4926      22.2984      22.2936      21.3667
450283......................................................      13.8916      14.5664      15.1950      14.5306
450286......................................................      12.1212            *            *      12.1212
450288......................................................      15.9878      16.2502      18.8935      16.9454
450289......................................................      18.3478      20.3104      20.3460      19.6703
450292......................................................      19.5050      16.9693      20.5335      18.8754
450293......................................................      14.4281      16.0132      16.2721      15.6074
450296......................................................      20.6628      21.6000      22.3430      21.5410
450299......................................................      17.9678      21.5672            *      19.7778
450303......................................................      12.6720      12.4582      12.8996      12.6812
450306......................................................      13.3165      13.8216      14.2047      13.8205
450307......................................................      16.6779      16.4622      17.0691      16.7424
450309......................................................      16.2055      13.1480      13.3771      14.0877
450315......................................................      20.8043      22.8140      21.4684      21.6913
450320......................................................      19.6331      20.0946      20.6596      20.1159
450321......................................................      13.3932      13.1752      14.7344      13.7774
450322......................................................      12.4570      22.7667      29.1884      20.6852
450324......................................................      17.8697      17.7886      19.1692      18.2493
450327......................................................      16.0935      11.7511      13.3639      13.4001
450330......................................................      18.4163      18.9425      19.8066      19.0827
450334......................................................      12.2721      12.8051      13.8392      12.9835
450337......................................................      17.4208      17.1073      25.5708      18.8965
450340......................................................      15.8519      17.6914            *      16.7663
450341......................................................      19.1828      18.9429            *      19.0666
450346......................................................      17.1038      17.5367      18.9475      17.8083
450347......................................................      17.6908      17.1099      19.3475      18.0306
450348......................................................      12.9414      13.9535      13.3585      13.4272
450351......................................................      15.9772      18.4116      19.3159      17.9591
450352......................................................      17.8528      18.7480      20.1871      18.9532
450353......................................................      15.0020      17.7539      16.0003      16.2513
450355......................................................      14.3182      11.9473      11.8933      12.5966
450358......................................................      21.2812      22.3235      23.0206      22.2174
450362......................................................      15.3536      15.8847      18.1983      16.4730
450369......................................................      15.1854      15.2233      15.3122      15.2420
450370......................................................      15.4368      12.6061      16.1369      14.6391
450371......................................................      11.8996      24.6339      16.0236      16.3341
450372......................................................      19.8589      20.0924      22.0746      20.6261
450373......................................................      17.5998      17.4183      17.9554      17.6614
450374......................................................      12.8264      13.6099      15.1750      13.8338
450378......................................................      23.1598      23.5789      23.4599      23.4221
450379......................................................      20.2756      22.7632      22.8756      21.9542
450381......................................................      15.6215      16.4166      16.7112      16.2538
450388......................................................      17.5561      19.2499      19.7408      18.8527
450389......................................................      18.1478      18.1797      18.8448      18.4036
450393......................................................      18.7387      20.2784      22.4992      20.3300
450395......................................................      16.6754      18.3768      18.0024      17.6923
450399......................................................      16.3066      15.7845      15.3491      15.8113
450400......................................................      14.0761      19.5379      18.6668      17.2665
450403......................................................      21.3691      20.1989      22.8430      21.4973
450411......................................................      14.0463      14.4832      15.1121      14.5493

[[Page 40026]]

 
450417......................................................      13.8517      13.4983      15.3591      14.2291
450418......................................................      20.5847      21.9161      21.9690      21.5007
450419......................................................      21.8196      20.6325      23.2551      21.9114
450422......................................................      24.5309      26.4848      28.0257      26.2815
450423......................................................      19.4352      22.7132            *      20.9607
450424......................................................      17.5658      18.9741      18.7895      18.4852
450429......................................................      11.3811      13.8723            *      12.4654
450431......................................................      16.2696      19.6304      22.0361      19.0606
450438......................................................      16.5461      19.5028      15.4553      17.0919
450446......................................................      21.9685      13.0986      20.7592      18.0346
450447......................................................      16.6124      18.0376      18.0377      17.5317
450451......................................................      19.6424      18.8948      18.2988      18.9126
450457......................................................      19.7689      24.7880      19.6569      21.1382
450460......................................................      14.2156      15.1765      14.6523      14.6666
450462......................................................      20.1347      22.6212      22.1144      21.6206
450464......................................................      13.4714      13.2931      15.5908      14.0563
450465......................................................      15.2203      15.5650      15.4731      15.4326
450467......................................................      15.6034      10.6184      17.0004      13.7745
450469......................................................      22.1012      19.6269      22.1930      21.2351
450473......................................................      14.1895      19.9761      19.7148      17.9827
450475......................................................      16.2489      16.3404      16.9269      16.5089
450484......................................................      19.5869      16.8131      18.9825      18.4097
450488......................................................      18.6813      19.3457      19.2173      19.0899
450489......................................................      14.5747       9.9326      16.3584      13.1235
450497......................................................      11.9242      15.0886      16.2997      14.3957
450498......................................................      12.0249      13.8551      14.4713      13.5076
450508......................................................      19.8722      18.8069      19.0991      19.2442
450514......................................................      22.2791      21.3243      20.0144      21.2387
450517......................................................      12.8702      27.8815      14.3191      16.6822
450518......................................................      19.0112      19.8116      21.4873      20.0415
450523......................................................      20.2589      20.0792      21.0393      20.4436
450530......................................................      22.9101      22.8623      21.1634      22.2676
450534......................................................      24.0835      19.9376      20.1520      21.2600
450535......................................................      21.2659      19.6645      21.0513      20.6461
450537......................................................      21.7432      20.8438      20.1161      20.8690
450538......................................................      19.6864            *            *      19.6864
450539......................................................      14.2536      16.4921      18.7559      16.5056
450544......................................................      19.3848      23.9283      23.6652      21.9211
450545......................................................      16.9674      19.5558      20.2823      18.9428
450547......................................................      13.8074      14.8248      18.1524      15.7208
450551......................................................      13.9069      16.9439      16.6237      15.8128
450558......................................................      20.0164      22.2574      20.7404      21.0120
450559......................................................      13.4572            *            *      13.4572
450561......................................................      16.8162            *            *      16.8162
450563......................................................      30.3744      19.9218      22.0708      22.9095
450565......................................................      16.4545      16.2652      17.3803      16.7063
450570......................................................      17.7135      18.9532      19.0336      18.5591
450571......................................................      16.9705      17.5598      18.2784      17.6264
450573......................................................      15.6698      12.2502      17.3518      14.9746
450574......................................................      14.2411      14.5965      14.6128      14.4845
450575......................................................      19.0613      19.3925      22.5621      20.3955
450578......................................................      16.8731      15.4783      18.0925      16.7620
450580......................................................      15.3581      15.8321      16.7374      16.0231
450583......................................................      15.5040      15.6580      14.4411      15.1895
450584......................................................      13.3747      14.2321      14.6735      14.1004
450586......................................................      12.8439      14.3773      13.8248      13.7154
450587......................................................      17.1124      17.0230      18.0219      17.3661
450591......................................................      17.9151      17.8981      17.7795      17.8608
450596......................................................      14.8232      22.5420      21.6729      19.1117
450597......................................................      16.1797      17.0776      17.6179      16.9806
450603......................................................      12.7682      11.6442      23.5572      15.3844
450604......................................................      15.4790      16.4535      17.6582      16.5641
450605......................................................      20.1541      21.1400      19.4580      20.2362

[[Page 40027]]

 
450609......................................................      10.7323      15.9753      17.0986      14.6244
450610......................................................      16.7464      18.9924      21.5191      19.2633
450614......................................................      13.8304      17.9853      16.5754      15.9153
450615......................................................      14.7457      14.8562      15.2956      14.9778
450617......................................................      19.5381      20.3387      20.8919      20.3006
450620......................................................      13.7063      15.8380      16.0987      15.2421
450623......................................................      21.8275      22.1950      23.1270      22.3514
450626......................................................      19.7896      18.1673      18.4349      18.7617
450628......................................................      16.8345      20.5611      18.6093      18.6475
450630......................................................      19.1904      21.6876      20.9605      20.5728
450631......................................................      17.5555      20.0417      21.6736      19.4992
450632......................................................      12.7295      11.7587      13.9147      12.7814
450633......................................................      20.7209      19.5183      19.4949      19.8926
450634......................................................      20.2932      23.5333      22.9877      22.3295
450638......................................................      19.6968      23.1437      22.1704      21.6228
450639......................................................      20.3050      23.1936      21.6421      21.6608
450641......................................................      13.5049      16.5125      15.7578      15.1652
450643......................................................      17.4268      18.7054      16.8152      17.6481
450644......................................................      20.7904      23.6587      22.7721      22.2903
450646......................................................      19.9866      19.8274      19.1433      19.6406
450647......................................................      22.4196      24.7981      24.2763      23.8588
450648......................................................      14.7541      14.8488      15.0305      14.8793
450649......................................................      15.8156      16.4496      16.6577      16.3245
450651......................................................      20.7304      22.7664      22.7112      22.1063
450652......................................................      16.6461      13.4389      17.2445      15.4912
450653......................................................      19.2847      18.1834      19.2349      18.8580
450654......................................................      13.8833      14.5258      14.5423      14.3223
450656......................................................      18.7328      17.6723      18.2606      18.1968
450658......................................................      15.1477      16.2657      17.2630      16.2787
450659......................................................      20.5609      22.2550      23.0108      21.9106
450661......................................................      20.2196      19.7160      18.9071      19.5857
450662......................................................      18.6797      18.2284      19.3152      18.7697
450665......................................................      15.4395      15.2015      16.1319      15.5906
450666......................................................      19.3456      20.3248      20.2549      19.9584
450668......................................................      18.7218      20.6965      21.0972      20.1590
450669......................................................      22.2832      21.7632      21.6746      21.8862
450670......................................................      18.2030      16.8893      20.2632      18.5133
450672......................................................      21.2079      21.8559      21.4927      21.5115
450673......................................................      13.8444      13.9620      13.7005      13.8283
450674......................................................      20.6151      22.2796      22.2426      21.7353
450675......................................................      23.2587      22.4961      21.4479      22.2858
450677......................................................      18.7905      22.6839      20.6556      20.7200
450678......................................................      20.7453      23.2617      24.1301      22.6596
450683......................................................      21.1748      20.9143      22.8699      21.6172
450684......................................................      22.8552      19.7005      21.9962      21.3850
450686......................................................      15.0122      16.5661      16.4632      15.9861
450688......................................................      20.8988      19.6250      20.1831      20.2348
450690......................................................      22.4118      21.6578      22.4707      22.1725
450694......................................................      18.4917      17.4758      18.1872      18.0283
450696......................................................      17.5701      24.9636            *      21.1885
450697......................................................      15.9259      18.8405      19.4949      18.0008
450698......................................................      14.3983      14.6680      15.4750      14.8475
450700......................................................      15.1153      14.6421      15.9050      15.2506
450702......................................................      21.0157      20.8223      21.3739      21.0706
450703......................................................      18.8029            *            *      18.8029
450704......................................................      21.6236      20.9821      20.7987      21.1724
450705......................................................      22.3175      30.0116      22.1809      24.2035
450706......................................................      21.3777      21.2072      22.0884      21.5769
450709......................................................      19.7741      20.8889      22.1490      21.0078
450711......................................................      18.2350      19.8126      19.8581      19.3268
450712......................................................      16.8942      13.6240      15.9298      15.4007
450713......................................................      23.6009      20.8065      22.6986      22.2836
450715......................................................      19.7719      22.0413      22.5988      21.5504

[[Page 40028]]

 
450716......................................................      19.9871      20.5544      20.9074      20.4812
450717......................................................      19.4546      20.7192      20.6551      20.2618
450718......................................................      19.0679      19.6886      22.1765      20.3069
450723......................................................      19.7044      19.7563      20.8213      20.1083
450724......................................................      20.0667      20.3235      20.3706      20.2569
450725......................................................      19.5572            *            *      19.5572
450727......................................................      17.7508      13.5458      17.9172      16.1802
450728......................................................      12.9277      17.5284      19.8879      16.6493
450730......................................................      20.9129      22.0819      23.0054      22.0459
450733......................................................      20.3718      20.7693      20.2199      20.4645
450735......................................................       8.0014      13.8767            *      10.0108
450742......................................................      20.7775      22.7655      21.8392      21.8145
450743......................................................      15.9493      18.8937      19.6015      18.1561
450746......................................................      20.7534      12.7904      30.2657      19.9075
450747......................................................      17.3842      19.2585      20.3914      18.9599
450749......................................................      12.9542      16.2130      19.1678      16.2656
450750......................................................      14.7207      14.6914      13.8098      14.4310
450751......................................................      22.2491      21.2198      19.9995      21.3756
450754......................................................      14.8896      16.0860      16.7145      15.9455
450755......................................................      14.7070      17.9904      19.8743      17.5601
450757......................................................      13.9636      13.8675      14.9434      14.2422
450758......................................................      18.6513      21.8669      19.0221      19.8347
450760......................................................      18.0690      17.4852      19.2225      18.2582
450761......................................................      11.1444      13.6152      15.7681      13.3382
450763......................................................      17.5603      18.2123      18.6092      18.1083
450766......................................................      21.8103      22.4348      23.3879      22.5926
450769......................................................      13.6183      14.5858      18.4163      15.2554
450770......................................................      16.8250      16.5458      19.0183      17.4436
450771......................................................      21.5814      22.4542      21.8268      21.9636
450774......................................................      16.5198      17.9964      16.2948      16.9482
450775......................................................      19.9651      19.8897      21.3504      20.4169
450776......................................................      10.1953      15.7750      14.1720      13.1591
450777......................................................      19.5923      21.0682      19.0380      19.9747
450779......................................................      22.9697      21.4546      21.6642      21.8768
450780......................................................      15.2800      19.1498      19.0914      17.6291
450785......................................................      18.5475      18.4976            *      18.5211
450788......................................................      20.9806      19.1463      19.6469      19.7295
450794......................................................      18.3981      18.2229            *      18.3485
450795......................................................      14.1682      16.6494      22.5753      17.9737
450796......................................................      17.4472      16.5362      19.2059      17.6627
450797......................................................      18.5901      15.9188      16.4923      16.8594
450798......................................................       9.2165       9.4634            *       9.3327
450801......................................................      16.6095      17.5669      17.9548      17.3668
450802......................................................      18.9018      19.9168      17.1435      18.5477
450803......................................................      16.2047      18.3767      21.6653      19.3492
450804......................................................      20.2223      19.4846      19.0893      19.5891
450807......................................................      13.2256      11.3192      13.4306      12.5547
450808......................................................      45.4728      16.9915      17.4917      21.1577
450809......................................................      19.0266      20.0202      19.7899      19.6416
450811......................................................      18.3847      19.0961      19.9168      19.1389
450812......................................................      20.7383            *            *      20.7383
450813......................................................            *      15.9166      14.5392      15.1549
450815......................................................            *            *      21.2741      21.2741
450819......................................................            *            *      16.5521      16.5521
450820......................................................            *            *      26.8348      26.8348
450822......................................................            *            *      22.8556      22.8556
460001......................................................      20.6336      21.7996      22.2735      21.5846
460003......................................................      20.5958      20.0452      22.6289      21.0329
460004......................................................      20.8196      21.3744      21.7234      21.3231
460005......................................................      17.5818      19.7069      22.5252      19.8732
460006......................................................      19.6485      20.6252      21.0700      20.4918
460007......................................................      20.5677      20.8026      21.1922      20.8840
460008......................................................      21.0338      18.8661      19.1153      19.6864

[[Page 40029]]

 
460009......................................................      21.1084      21.9016      22.5295      21.8515
460010......................................................      21.2473      21.9830      22.4948      21.9354
460011......................................................      16.7114      18.8660      19.7674      18.3702
460013......................................................      20.3331      20.7326      20.1936      20.4306
460014......................................................      19.5465      18.3865      18.5370      18.7488
460015......................................................      20.0987      20.6593      21.0470      20.6197
460016......................................................      18.0791      18.2408      21.9105      19.2998
460017......................................................      26.0310      17.7103      18.9929      19.9984
460018......................................................      16.8566      17.6235      17.0063      17.1606
460019......................................................      17.3683      16.2671      17.8690      17.1417
460020......................................................      17.0271      17.3467      17.2663      17.2239
460021......................................................      20.2613      21.0470      21.5174      20.9913
460022......................................................      18.2100      20.1534      21.3614      19.7210
460023......................................................      21.3321      22.3535      22.9265      22.2381
460024......................................................      13.0279            *            *      13.0279
460025......................................................      12.5083      19.4247      17.3494      16.5301
460026......................................................      17.3431      19.9241      20.2576      19.0202
460027......................................................      20.8331      21.8868      22.2955      21.6637
460029......................................................      17.2501      20.5154      20.8366      19.2190
460030......................................................      17.2196      17.6071      17.1383      17.3160
460032......................................................      19.5474      21.1006      21.4832      20.7171
460033......................................................      15.7233      19.5372      19.2664      18.1972
460035......................................................      14.2802      16.0021      16.1685      15.4874
460036......................................................      22.3788      23.5893      23.4573      23.1384
460037......................................................      18.7665      18.6850      17.7399      18.3920
460039......................................................      24.4781      24.9134      24.4808      24.6217
460041......................................................      21.6926      21.0623      20.2035      20.9715
460042......................................................      17.8455      18.8814      19.5662      18.7473
460043......................................................      23.8970      24.4779      23.2819      23.8380
460044......................................................      20.6897      21.4696      21.8485      21.3516
460046......................................................      17.1085      18.2224            *      17.6742
460047......................................................      21.3843      23.0433      22.7524      22.4777
460049......................................................      18.8206      19.6483      20.8283      19.8892
460050......................................................      26.2485            *            *      26.2485
460051......................................................      20.9797      19.4761      22.1758      20.8643
460052......................................................            *            *      19.8961      19.8961
470001......................................................      19.6108      20.2299      21.3817      20.4021
470003......................................................      22.5949      23.6949      22.0563      22.7712
470004......................................................      18.0952      16.8842      18.1879      17.7051
470005......................................................      21.5151      21.9191      23.1808      22.1962
470006......................................................      18.3898      17.8699      20.2829      18.8123
470008......................................................      19.4136      19.6069      20.1969      19.7378
470010......................................................      19.4652      20.2961      21.0616      20.2790
470011......................................................      21.2014      21.7675      22.2415      21.7386
470012......................................................      18.5162      18.5339      18.9444      18.6579
470015......................................................      19.2552      19.5366      20.2125      19.6399
470018......................................................      20.4161      21.5426      21.2406      21.0610
470020......................................................      18.9884      20.6643      21.5688      20.4558
470023......................................................      20.6391      20.4511      21.7139      20.9439
470024......................................................      20.4087      20.8510      21.9807      21.0777
490001......................................................      24.7604      21.9755      20.0570      22.0422
490002......................................................      12.9871      15.2287      15.7365      14.6222
490003......................................................      18.0034      19.1040      20.3237      19.1299
490004......................................................      18.7731      19.2126      19.7074      19.2382
490005......................................................      16.9087      20.5517      21.3318      19.6257
490006......................................................      15.2276      15.9537      12.3253      14.5928
490007......................................................      18.4330      18.7740      19.8938      19.0586
490009......................................................      22.9513      23.9344      23.7659      23.5499
490010......................................................      18.5780      21.7424            *      19.9381
490011......................................................      18.7508      18.6071      19.8042      19.0282
490012......................................................      13.7788      15.9973      15.2965      15.0022
490013......................................................      16.9324      17.3318      18.2396      17.5085
490014......................................................      24.5557      25.8315      23.5266      24.6242

[[Page 40030]]

 
490015......................................................      19.3608      19.6363      20.0667      19.6821
490017......................................................      17.3152      18.4361      19.3854      18.3964
490018......................................................      17.9433      18.3435      18.5508      18.2858
490019......................................................      17.5309      19.6178      21.0124      19.4215
490020......................................................      17.6655      18.5691      19.3424      18.5533
490021......................................................      19.4490      19.3945      20.0496      19.6794
490022......................................................      20.7223      21.2183      22.3380      21.4351
490023......................................................      18.9587      20.6694      21.5683      20.4224
490024......................................................      16.8904      17.7221      18.4314      17.8400
490027......................................................      14.4234      16.2761      16.7556      15.8360
490030......................................................      10.5029       9.1789       8.6446       9.5559
490031......................................................      15.8213      14.9539      16.0003      15.5875
490032......................................................      21.5592      22.4262      21.4037      21.7854
490033......................................................      18.3265      21.1723      19.2908      19.5511
490037......................................................      15.9704      16.3759      17.0113      16.4399
490038......................................................      15.7099      21.0218      17.6324      17.9048
490040......................................................      22.5237      22.7061      24.1266      23.1321
490041......................................................      16.5542      18.3589      18.7987      17.8901
490042......................................................      15.2717      16.4666      17.0972      16.2668
490043......................................................      20.6775      22.1574      22.1068      21.7221
490044......................................................      17.6282      18.3137      19.7842      18.6148
490045......................................................      19.6325      20.5468      20.5558      20.2593
490046......................................................      18.6112      18.4825      19.9102      19.0232
490047......................................................      17.1631      25.0438      18.7614      19.8637
490048......................................................      17.8907      18.4361      19.5417      18.6005
490050......................................................      22.7129      23.0729      23.3668      23.0530
490052......................................................      16.9363      16.8600      16.4787      16.7609
490053......................................................      15.6883      15.6996      16.8410      16.1062
490054......................................................      15.5516      15.4734      19.5780      16.7024
490057......................................................      19.0668      19.9210      20.3160      19.7770
490059......................................................      20.3744      20.8662      21.4801      20.8999
490060......................................................      19.2006      17.6308      18.5917      18.4363
490063......................................................      28.2527      28.6536      26.1930      27.6341
490066......................................................      16.5024      20.6972      19.8352      18.9146
490067......................................................      17.1922      17.0195      17.8487      17.3549
490069......................................................      15.6986      17.3297      20.7582      17.8379
490071......................................................      19.4701      21.8879      23.3511      21.4480
490073......................................................      26.1420      20.7960      26.0957      24.1488
490074......................................................      19.3417            *            *      19.3417
490075......................................................      19.1906      18.6983      19.2156      19.0267
490077......................................................      19.7866      21.3670      22.6504      21.2469
490079......................................................      16.4379      17.0815      17.7016      17.0749
490083......................................................      16.6406            *            *      16.6406
490084......................................................      16.3846      16.7834      18.0555      17.0646
490085......................................................      16.3979      17.4584      17.6158      17.1539
490088......................................................      15.5982      16.4362      17.9141      16.6068
490089......................................................      15.8618      17.7692      18.2290      17.2642
490090......................................................      16.2785      17.0199      17.5799      16.9734
490091......................................................      19.9949      20.8734      25.0272      21.8088
490092......................................................      15.6893      16.9533      16.4360      16.3528
490093......................................................      16.4767      17.3711      17.8275      17.2502
490094......................................................      16.7880      18.9204      22.3033      19.3562
490095......................................................      18.2495            *            *      18.2495
490097......................................................      15.8586      15.5780      16.9518      16.0789
490098......................................................      14.6971      15.1403      16.0488      15.2544
490099......................................................      16.8667      17.9665      18.3985      17.7293
490100......................................................      17.2189      22.5010            *      19.8823
490101......................................................      25.0907      24.7616      23.5553      24.4275
490104......................................................      28.4910      25.6889      40.2529      29.2590
490105......................................................      18.2461      18.5765      21.4428      19.2491
490106......................................................      16.9117      17.6596      26.3821      18.9838
490107......................................................      22.4054      23.5240      22.9283      22.9660
490108......................................................      19.7478      20.2112      24.1232      21.0559

[[Page 40031]]

 
490109......................................................      21.1589      23.6620      25.9475      23.4402
490110......................................................      15.8408      16.5131      18.1561      16.8181
490111......................................................      17.3453      17.1768      17.8510      17.4580
490112......................................................      20.5239      21.4532      22.1162      21.3613
490113......................................................      23.0840      23.2235      23.9043      23.4071
490114......................................................      16.9083      17.3047      18.0359      17.4375
490115......................................................      17.1023      16.5203      16.8537      16.8239
490116......................................................      16.4436      16.6170      17.2040      16.7676
490117......................................................      13.8429      14.0104      14.7944      14.2244
490118......................................................      20.8707      21.4674      23.2022      21.8304
490119......................................................      17.8686      17.9147      18.6046      18.1353
490120......................................................      19.9810      19.3707      20.5777      19.9742
490122......................................................      23.9695      23.8801      23.8198      23.8925
490123......................................................      16.8505      17.7461      19.3056      18.0001
490124......................................................      19.3616      22.0884      21.3818      20.8857
490126......................................................      18.2276      18.6844      20.4294      19.0254
490127......................................................      14.4815      16.0516      16.5993      15.6547
490129......................................................      27.4701      22.5885      28.6868      25.1130
490130......................................................      16.2779      16.4322      17.6943      16.7915
490132......................................................      17.0204      18.6570      18.4671      18.0649
500001......................................................      21.3476      22.1896      24.4829      22.6367
500002......................................................      21.0375      21.6332      19.8476      20.7811
500003......................................................      24.3055      24.2814      24.4333      24.3392
500005......................................................      23.4808      22.3955      24.3870      23.3703
500007......................................................      22.4269      26.0599      21.9911      23.4148
500008......................................................      24.1930      25.3064      26.1737      25.2130
500011......................................................      25.1836      24.0162      24.6554      24.5938
500012......................................................      22.2815      20.7032      24.2799      22.3541
500014......................................................      23.9276      24.3419      24.0990      24.1249
500015......................................................      23.2435      23.9297      24.9923      24.0554
500016......................................................      23.9034      24.3938      24.9439      24.4287
500019......................................................      22.3668      22.4213      23.2054      22.6470
500021......................................................      24.4622      25.9198      27.6490      25.9957
500023......................................................      27.1892      26.6535      27.1025      26.9568
500024......................................................      24.0453      23.7472      26.6452      24.7736
500025......................................................      23.9557      26.4810      24.4825      24.9695
500026......................................................      23.3491      23.8005      26.9884      24.7238
500027......................................................      25.0529      22.2158      25.1125      24.0804
500028......................................................      18.8588      19.2675      18.9556      19.0337
500029......................................................      16.8083      17.9237      18.5042      17.7373
500030......................................................      24.1321      24.9039      26.3828      25.1714
500031......................................................      23.3659      29.2707      23.6099      25.1784
500033......................................................      21.3906      22.3527      22.5462      22.1428
500036......................................................      21.8950      22.1096      23.6333      22.5254
500037......................................................      19.6803      20.7139      21.4059      20.6062
500039......................................................      23.3211      23.8918      24.0007      23.7403
500041......................................................      24.8556      23.9608      25.4376      24.7549
500042......................................................      22.1286      22.9125            *      22.5386
500043......................................................      20.2509      20.9459      22.0466      21.0230
500044......................................................      23.1128      23.3364      24.2212      23.5535
500045......................................................      22.0982      20.8881      24.0526      22.2906
500048......................................................      19.3029      22.1906      20.3207      20.5960
500049......................................................      22.9534      24.0489      24.5997      23.8657
500050......................................................      20.9445      22.0065      22.6563      21.9092
500051......................................................      24.4769      24.8203      25.9447      25.1087
500053......................................................      22.0515      23.9397      22.8399      22.9429
500054......................................................      22.9024      22.8829      23.8089      23.1889
500055......................................................      22.8769      23.7446      23.8622      23.5097
500057......................................................      18.0424      18.2737      19.0479      18.4516
500058......................................................      23.3984      24.7882      24.1106      24.0962
500059......................................................      22.5412      23.3506      26.6270      24.1016
500060......................................................      23.5360      25.0233      28.3655      25.4628
500061......................................................      20.3957      21.7013      20.8624      20.9851

[[Page 40032]]

 
500062......................................................      19.4607      18.6329      19.0557      19.0333
500064......................................................      24.5283      25.5748      26.7000      25.6273
500065......................................................      21.4254      21.9308      23.5671      22.3106
500068......................................................      18.6960      19.6574      19.2638      19.2003
500069......................................................      20.6262      21.3592      21.4542      21.1522
500071......................................................      19.3810      19.1906      19.1428      19.2439
500072......................................................      24.4599      25.3928      25.2001      25.0228
500073......................................................      21.4303      21.2469      21.7698      21.4835
500074......................................................      18.6506      18.9679      19.5981      19.0849
500077......................................................      23.2056      22.8536      23.9410      23.3357
500079......................................................      22.9809      24.2036      23.1041      23.4248
500080......................................................      13.8000      15.6630      18.3883      15.5897
500084......................................................      22.2169      23.4032      24.4044      23.3798
500085......................................................      28.6121      21.4403      20.4517      22.7948
500086......................................................      22.3132      23.3288      22.8829      22.8469
500088......................................................      23.6988      23.2701      25.2478      24.0737
500089......................................................      17.9399      18.7080      19.7166      18.7736
500090......................................................      16.3297      16.1576      20.4429      17.2562
500092......................................................      17.2881      16.7913      19.2028      17.7527
500094......................................................      18.1080      18.5835      15.7866      17.6577
500096......................................................      20.9580      21.0151      23.3564      21.7716
500097......................................................      20.8010      19.7706      20.8774      20.4568
500098......................................................      12.9935      16.3511      15.2040      14.9340
500101......................................................      19.4498      19.7337      15.8000      18.3994
500102......................................................      20.3321      20.9389      21.8963      21.0615
500104......................................................      22.5849      22.8154      24.9389      23.3843
500106......................................................      18.7087      18.6041      19.1465      18.7914
500107......................................................      17.2987      18.1201      17.9489      17.8064
500108......................................................      27.2126      26.2939      28.6229      27.3944
500110......................................................      21.4053      21.4553      22.9775      21.9505
500118......................................................      22.9245      23.8397      24.8034      23.8697
500119......................................................      21.5704      22.4373      22.1192      22.0436
500122......................................................      21.9135      22.4268      23.5264      22.6230
500123......................................................      19.5855      20.3181      19.6646      19.8819
500124......................................................      24.1473      23.2836      23.7742      23.7287
500125......................................................      16.6272      15.1112      14.7910      15.5165
500129......................................................      23.5952      26.1575      25.4685      25.1115
500132......................................................      19.3567      15.6717      23.1822      19.3937
500134......................................................      20.9570      17.7457      17.2430      18.5700
500139......................................................      20.8816      22.2297      22.3053      21.8379
500141......................................................      22.9358      23.8838      29.9695      25.5485
500143......................................................      17.6031      18.0343      18.2570      17.9797
500146......................................................      17.8558      21.6003            *      19.6218
510001......................................................      17.8282      19.1492      20.0429      18.9855
510002......................................................      17.3409      20.1527      17.6392      18.3009
510005......................................................      14.4330      14.2503      13.8621      14.1872
510006......................................................      17.8821      18.7313      19.9609      18.8717
510007......................................................      20.2483      21.2729      21.6761      21.0848
510008......................................................      17.3653      18.3296      19.0513      18.2388
510012......................................................      16.5037      15.8390      15.6089      15.9887
510013......................................................      16.6194      17.8527      19.5798      17.9628
510015......................................................      14.7904      14.9039      16.7311      15.5193
510016......................................................      12.0276            *            *      12.0276
510018......................................................      16.4757      18.5269      18.5358      17.8403
510020......................................................      12.6472      13.1837      14.1211      13.3435
510022......................................................      19.8375      20.1763      21.5770      20.5146
510023......................................................      15.9417      16.0129      16.7777      16.2444
510024......................................................      18.7982      19.0941      18.7461      18.8794
510026......................................................      13.4586      13.6888      13.7952      13.6491
510027......................................................      17.5759      17.2900      18.5945      17.8135
510028......................................................      20.7306      20.0628      19.9208      20.2198
510029......................................................      17.0519      17.7124      18.4668      17.7625
510030......................................................      18.3137      17.4198      17.7603      17.8189

[[Page 40033]]

 
510031......................................................      18.4887      28.6673      18.6341      21.0020
510033......................................................      18.8061      18.4082      18.4718      18.5670
510035......................................................      18.6471      16.5007      18.3164      17.7425
510036......................................................      13.1995      13.4559      13.8786      13.5021
510038......................................................      14.3433      15.8132      15.5576      15.2710
510039......................................................      16.0555      16.9398      17.1461      16.7060
510043......................................................      14.2872      14.0662      13.1308      13.8129
510046......................................................      17.7320      17.3821      18.5896      17.9120
510047......................................................      19.1202      19.8963      20.8101      19.9042
510048......................................................      20.3734      21.0407      17.1647      19.5052
510050......................................................      16.5681      16.9136      18.4036      17.3154
510053......................................................      15.5856      16.1036      17.5798      16.4010
510055......................................................      22.8376      23.7248      24.2133      23.6043
510058......................................................      17.9786      18.4156      18.4501      18.2860
510059......................................................      16.7732      16.5854      16.1044      16.5068
510060......................................................      15.6581      17.5594            *      16.5969
510061......................................................      14.2227      13.8204      14.1968      14.0767
510062......................................................      17.6276      19.3881      18.1588      18.4173
510065......................................................      14.5882            *            *      14.5882
510066......................................................      12.7164      12.2943            *      12.5091
510067......................................................      18.1079      16.7161      17.3067      17.3634
510068......................................................      16.2864      18.7938      23.0452      19.1223
510070......................................................      16.3616      18.5146      18.7091      17.9505
510071......................................................      16.2390      17.2148      18.0278      17.1797
510072......................................................      17.6579      15.6262      15.9257      16.4174
510077......................................................      16.4111      18.0668      18.2947      17.6316
510080......................................................      14.7966      17.4485      16.3453      16.1690
510081......................................................      13.0020      13.6359      11.9701      12.8648
510082......................................................      13.6905      17.4538      13.5946      14.7307
510084......................................................      12.4820      17.2395      13.5339      14.4076
510085......................................................      18.6367      17.5624      18.6227      18.2581
510086......................................................      13.7937      13.4763      14.2241      13.8304
510088......................................................            *            *      14.8854      14.8854
520002......................................................      18.3521      19.7447      19.6755      19.2773
520003......................................................      16.4334      17.1248      18.7956      17.5028
520004......................................................      18.1744      19.6512      20.4591      19.4206
520006......................................................      20.4446      21.5313      21.4884      21.1400
520007......................................................      13.1087      16.2001      18.4629      16.0134
520008......................................................      22.8024      22.8024      24.9395      23.5372
520009......................................................      18.5094      18.6002      21.4638      19.4842
520010......................................................      20.3447      22.7703      22.3311      21.8215
520011......................................................      20.3797      20.7410      21.5223      20.8830
520013......................................................      21.6289      20.3965      20.5944      20.8585
520014......................................................      16.3989      17.1646      18.0841      17.1764
520015......................................................      18.3185      18.6078      19.7672      18.9031
520016......................................................      13.2889      17.3018      18.4320      16.1862
520017......................................................      19.3179      19.6008      19.4780      19.4685
520018......................................................      18.6441      21.1941      21.5279      20.5280
520019......................................................      18.3143      19.5440      20.9164      19.5698
520021......................................................      20.0355      21.3471      21.9531      21.1390
520024......................................................      14.6107      14.0175      14.4750      14.3609
520025......................................................      18.1086      18.2430      20.3838      18.8661
520026......................................................      19.8131      21.5453      20.8546      20.7335
520027......................................................      18.9085      19.9324      21.5868      20.1744
520028......................................................      19.1370      21.2852      22.5941      20.9020
520029......................................................      16.7520      19.5750      21.4197      19.2161
520030......................................................      20.0043      20.5039      21.6311      20.7089
520031......................................................      18.7066      20.4814      20.9875      19.9520
520032......................................................      17.9007      19.5697      21.1069      19.5434
520033......................................................      18.8906      19.2954      20.2520      19.4725
520034......................................................      16.6858      17.1282      20.4307      18.0336
520035......................................................      17.0997      18.9452      18.7135      18.2608
520037......................................................      20.0516      20.6686      21.6017      20.7624

[[Page 40034]]

 
520038......................................................      17.7074      19.6294      20.6130      19.3169
520039......................................................      19.5990      20.7641      23.3687      21.1069
520040......................................................      20.7420      20.4677      21.2023      20.8002
520041......................................................      15.3666      17.1959      18.4117      16.9517
520042......................................................      17.6577      18.5843      19.5466      18.6338
520044......................................................      17.7932      18.4014      19.1877      18.4535
520045......................................................      19.6736      20.5917      21.2427      20.5162
520047......................................................      17.8702      18.3048      20.3487      18.7633
520048......................................................      19.1712      20.6583      19.8926      19.9142
520049......................................................      19.5727      20.3559      20.1667      20.0444
520051......................................................      19.7416      21.6497      24.0460      21.7205
520053......................................................      16.4887      17.3945      18.0851      17.3336
520054......................................................      15.9873      15.1747      16.8363      15.9586
520057......................................................      18.3186      19.0872      19.8492      19.0812
520058......................................................      18.1264      19.7283      21.2500      19.7133
520059......................................................      19.8530      20.9913      21.5796      20.8254
520060......................................................      17.1675      17.9258      18.8232      17.9582
520062......................................................      17.8000      19.1482      19.7038      18.8681
520063......................................................      20.7744      19.6136      20.5262      20.3055
520064......................................................      21.4586      22.7423      22.0917      22.0917
520066......................................................      22.4419      22.8837      24.0087      23.0580
520068......................................................      18.0798      18.9943      19.6855      18.9053
520069......................................................      17.9133      20.2934      20.1770      19.3716
520070......................................................      17.8192      18.5938      19.4261      18.6155
520071......................................................      18.7861      18.7304      19.9866      19.1576
520074......................................................      18.6923      20.4601      20.9007      20.0036
520075......................................................      19.0891      19.8457      20.7301      19.8876
520076......................................................      16.5072      17.6088      19.5878      17.8567
520077......................................................      15.5427      17.7830      18.7119      17.3266
520078......................................................      20.5559      21.3380      21.7545      21.2404
520082......................................................      16.7417      17.7405            *      17.1848
520083......................................................      22.5715      23.8849      23.5787      23.3411
520084......................................................      18.9475      20.8427      23.5446      21.0737
520087......................................................      19.3942      20.3624      20.7821      20.1850
520088......................................................      20.1529      20.6312      21.8931      20.8632
520089......................................................      20.6110      21.5456      22.1055      21.4053
520090......................................................      18.0026      18.9343      20.3645      19.1272
520091......................................................      20.0693      20.9927      20.9440      20.6686
520092......................................................      17.5577      17.6500      18.6248      17.9402
520094......................................................      19.7791      20.3611      20.6179      20.2438
520095......................................................      18.5066      20.3269      18.6425      19.1370
520096......................................................      19.2980      19.7757      20.6668      19.9365
520097......................................................      19.6470      20.2354      20.8016      20.2268
520098......................................................      20.0289      22.3348      23.4707      21.9054
520100......................................................      18.3788      18.3832      19.4788      18.7419
520101......................................................      17.8453      19.5186      19.9875      19.1542
520102......................................................      19.8354      20.1898      21.0138      20.3351
520103......................................................      21.2324      19.4809      20.1092      20.2137
520107......................................................      20.5441      20.3747      21.7907      20.8828
520109......................................................      18.6322      19.1303      19.7609      19.1753
520110......................................................      20.0319      20.4494      21.0055      20.5065
520111......................................................      17.2388      17.7834      17.7673      17.6163
520112......................................................      18.1827      19.1797      18.9577      18.7858
520113......................................................      20.5925      21.1485      21.8852      21.2341
520114......................................................      17.3799      16.6616      17.8476      17.2735
520115......................................................      17.3755      18.2980      19.2248      18.2555
520116......................................................      18.5698      19.8509      20.6922      19.7165
520117......................................................      17.4242      18.5414      18.3963      18.1365
520118......................................................      12.4422      14.2326      14.8626      13.8369
520120......................................................      15.6205      18.7437            *      17.3887
520121......................................................      17.5851      19.7305      20.8492      19.5992
520122......................................................      16.7552      16.2436      16.9335      16.6326
520123......................................................      17.4135      17.3980      17.7986      17.5610

[[Page 40035]]

 
520124......................................................      16.3902      17.2619      17.9205      17.1864
520130......................................................      15.1639      15.6845      16.6873      15.8395
520131......................................................      18.8043      18.7295      20.2591      19.2549
520132......................................................      17.2759      15.6379      18.1630      16.9564
520134......................................................      17.6094      18.0953      18.8150      18.1846
520135......................................................      14.4748      15.8246      17.3476      15.9083
520136......................................................      19.9935      19.8480      20.9050      20.2727
520138......................................................      20.8922      21.2260      22.5599      21.5577
520139......................................................      21.2797      20.9988      21.4042      21.2251
520140......................................................      21.4175      21.5207      22.3671      21.7731
520141......................................................      16.9543            *            *      16.9543
520142......................................................      17.7003      20.5858      21.9432      19.9586
520144......................................................      16.6231      18.5701      19.9120      18.4107
520145......................................................      17.2356      18.2654      18.7958      18.1015
520146......................................................      15.7318      17.9585      18.2370      17.3448
520148......................................................      16.9293      17.2421      19.1502      17.8057
520149......................................................      13.3032      14.1901      12.8928      13.4360
520151......................................................      18.0771      17.3267      18.7070      18.0230
520152......................................................      21.3333      19.5858      22.5980      21.0747
520153......................................................      15.4467      15.9753      17.0863      16.1441
520154......................................................      17.9229      18.5403      19.5994      18.6875
520156......................................................      19.8396      21.3377      20.9638      20.7243
520157......................................................      17.2784      17.1974      19.6008      18.0185
520159......................................................      18.7423      18.6760      17.7649      18.3871
520160......................................................      18.8444      19.4173      20.5154      19.5953
520161......................................................      18.5742      19.4905      20.1102      19.4069
520170......................................................      22.5033      21.5233      21.9857      21.9871
520171......................................................      15.7316      17.4560      18.0785      17.1053
520173......................................................      20.1410      21.3016      20.9209      20.7812
520177......................................................      21.7609      22.7221      24.0139      22.8278
520178......................................................      17.0411      18.6936      20.9010      18.7748
520188......................................................            *      13.9135            *      13.9135
530002......................................................      17.5888      19.3273      21.0560      19.3920
530003......................................................      15.7813      16.2139      15.9523      15.9820
530004......................................................      16.1862      15.0497      13.3788      14.7758
530005......................................................      15.1487      13.3529      15.3255      14.5529
530006......................................................      19.3403      18.5894      19.1305      19.0082
530007......................................................      18.0601      18.5161      17.7897      18.1450
530008......................................................      22.9625      18.8349      19.0113      20.0471
530009......................................................      19.4478      22.5009      21.7795      21.2113
530010......................................................      18.9317      21.6092      13.9536      17.6719
530011......................................................      17.4412      18.7354      19.4606      18.5542
530012......................................................      19.4829      18.9923      21.1854      19.8564
530014......................................................      17.3158      18.0869      18.4900      17.9675
530015......................................................      22.6465      22.4568      23.4040      22.8118
530016......................................................      17.7084      18.1562      19.3205      18.4153
530017......................................................      13.7131      16.3478      17.7736      15.9421
530018......................................................      17.8699      18.3783      19.5986      18.6254
530019......................................................      16.7630      18.5430      20.1097      18.3351
530022......................................................      17.8781      18.5002      19.6136      18.7082
530023......................................................      20.7527      20.1948      20.0677      20.3449
530025......................................................      20.3200      21.2598      22.0300      21.1974
530026......................................................      18.9175      17.0118      19.8969      18.4992
530027......................................................      29.7722      18.1664      25.5067      22.9705
530029......................................................      17.7993      16.5092      19.3361      17.7626
530031......................................................      13.3775      18.3322      20.1734      17.2600
530032......................................................      20.2143      21.0361      20.0132      20.4281
----------------------------------------------------------------------------------------------------------------
*Asterisk denotes wage data not available for the provider that year.
**The 3-year average hourly wage is weighted by salaries and hours.

      
  

  

  Federal Register / Vol. 66, No. 148 / Wednesday, August 1, 2001 / 
Rules and Regulations  

[[Page 40036]]


      

   Table 3A.--FY 2002 and 3-Year* Average Hourly Wage for Urban Areas
[*Based on the sum of the salaries and hours computed for Federal fiscal
                       years 2000, 2001, and 2002]
------------------------------------------------------------------------
                                                     FY 2002     3-Year
                                                     Average    Average
                    Urban Area                        Hourly     Hourly
                                                       Wage       Wage
------------------------------------------------------------------------
Abilene, TX.......................................    17.7691    17.6806
Aguadilla, PR.....................................    10.4485     9.2769
Akron, OH.........................................    22.0323    21.5752
Albany, GA........................................    23.7363    22.4591
Albany-Schenectady-Troy, NY.......................    18.9628    18.7015
Albuquerque, NM...................................    21.7519    19.8583
Alexandria, LA....................................    17.9113    17.4211
Allentown-Bethlehem-Easton, PA....................    22.4824    21.9015
Altoona, PA.......................................    20.3592    20.1685
Amarillo, TX......................................    19.4329    18.7074
Anchorage, AK.....................................    28.0436    27.7208
Ann Arbor, MI.....................................    24.7586    24.5264
Anniston, AL......................................    18.4627    18.1432
Appleton-Oshkosh-Neenah, WI.......................    20.6158    19.7313
Arecibo, PR.......................................    10.3287    10.1229
Asheville, NC.....................................    20.5253    19.9864
Athens, GA........................................    21.9578    21.2433
Atlanta, GA.......................................    22.4386    21.9090
Atlantic-Cape May, NJ.............................    25.1942    24.4875
Auburn-Opelika, AL................................    18.3605    17.4403
Augusta-Aiken, GA-SC..............................    22.2437    20.3470
Austin-San Marcos, TX.............................    21.4095    20.5134
Bakersfield, CA...................................    21.2373    20.8780
Baltimore, MD.....................................    21.9879    21.1182
Bangor, ME........................................    21.4017    20.8620
Barnstable-Yarmouth, MA...........................    30.3987    29.5566
Baton Rouge, LA...................................    18.1796    18.6154
Beaumont-Port Arthur, TX..........................    18.8344    18.7128
Bellingham, WA....................................    26.3828    25.1714
Benton Harbor, MI.................................    19.8256    18.8187
Bergen-Passaic, NJ................................    26.0785    25.7821
Billings, MT......................................    20.8647    20.9984
Biloxi-Gulfport-Pascagoula, MS....................    18.8292    17.8351
Binghamton, NY....................................    18.8434    18.7661
Birmingham, AL....................................    19.6498    19.0252
Bismarck, ND......................................    17.8118    16.9730
Bloomington,IN....................................    19.7257    18.9710
Bloomington-Normal, IL............................    20.1643    19.6505
Boise City, ID....................................    20.1899    19.6753
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH..    25.1952    24.5070
Boulder-Longmont, CO..............................    21.8607    21.3813
Brazoria, TX......................................    18.3149    18.3834
Bremerton, WA.....................................    24.0007    23.7403
Brownsville-Harlingen-San Benito, TX..............    20.1061    19.5499
Bryan-College Station, TX.........................    20.8102    18.8209
Buffalo-Niagara Falls, NY.........................    21.1015    20.7620
Burlington, VT....................................    22.0478    22.5833
Caguas, PR........................................    10.4833    10.0219
Canton-Massillon, OH..............................    19.9801    19.0700
Casper, WY........................................    21.1855    19.8564
Cedar Rapids, IA..................................    19.4080    19.1733
Champaign-Urbana, IL..............................    20.7605    20.0368
Charleston-North Charleston, SC...................    20.5383    19.7662
Charleston, WV....................................    20.6672    20.0125
Charlotte-Gastonia-Rock Hill, NC-SC...............    20.8279    20.4253
Charlottesville, VA...............................    23.5721    23.1481
Chattanooga, TN-GA................................    20.9025    20.9736
Cheyenne, WY......................................    18.4900    17.9675
Chicago, IL.......................................    24.6432    23.9647
Chico-Paradise, CA................................    21.9881    21.8619
Cincinnati, OH-KY-IN..............................    21.1338    20.5246
Clarksville-Hopkinsville, TN-KY...................    18.5997    17.8563
Cleveland-Lorain-Elyria, OH.......................    21.0982    20.8296
Colorado Springs, CO..............................    21.7395    20.8047
Columbia, MO......................................    19.3787    19.2453
Columbia, SC......................................    21.1766    20.5897
Columbus, GA-AL...................................    18.8304    18.5114
Columbus, OH......................................    21.3384    21.0849
Corpus Christi, TX................................    18.6084    18.6824
Corvallis, OR.....................................    25.9828    24.7413
Cumberland, MD-WV.................................    18.5294    18.4566
Dallas, TX........................................    22.1658    21.3656
Danville, VA......................................    19.2156    19.0267
Davenport-Moline-Rock Island, IA-IL...............    19.2716    19.0340
Dayton-Springfield, OH............................    20.5800    20.3849
Daytona Beach, FL.................................    20.0167    19.7043
Decatur, AL.......................................    19.5764    18.8565
Decatur, IL.......................................    17.8196    17.7118
Denver, CO........................................    23.0415    22.2645
Des Moines, IA....................................    19.5864    19.3257
Detroit, MI.......................................    23.3966    22.7762
Dothan, AL........................................    17.7316    17.1772
Dover, DE.........................................    22.9706    21.5842
Dubuque, IA.......................................    19.0053    18.6795
Duluth-Superior, MN-WI............................    22.9429    22.1011
Dutchess County, NY...............................    23.4959    22.7248
Eau Claire, WI....................................    19.8536    19.3107
El Paso, TX.......................................    20.5588    19.9419
Elkhart-Goshen, IN................................    21.5029    20.4359
Elmira, NY........................................    18.7740    18.4812
Enid, OK..........................................    18.6448    18.0515
Erie, PA..........................................    19.4447    19.3682
Eugene-Springfield, OR............................    25.5919    23.9337
Evansville, Henderson, IN-KY......................    18.9936    18.1304
Fargo-Moorhead, ND-MN.............................    20.6740    19.3632
Fayetteville, NC..................................    20.1393    19.0183
Fayetteville-Springdale-Rogers, AR................    18.8407    17.4532
Flagstaff, AZ-UT..................................    23.5500    22.9479
Flint, MI.........................................    24.3455    24.0039
Florence, AL......................................    17.5023    16.9533
Florence, SC......................................    19.4593    18.9517
Fort Collins-Loveland, CO.........................    22.4100    22.4773
Fort Lauderdale, FL...............................    22.9622    22.1804
Fort Myers-Cape Coral, FL.........................    20.9121    19.9782
Fort Pierce-Port St. Lucie, FL....................    22.7860    21.5773
Fort Smith, AR-OK.................................    17.9648    17.3902
Fort Walton Beach, FL.............................    20.0841    19.8202
Fort Wayne, IN....................................    20.5313    19.5510
Fort Worth-Arlington, TX..........................    20.9570    20.8452
Fresno, CA........................................    22.2730    22.0075
Gadsden, AL.......................................    19.6146    18.7634
Gainesville, FL...................................    21.1521    21.4897
Galveston-Texas City, TX..........................    23.0087    21.6646
Gary, IN..........................................    21.2620    20.5771
Glens Falls, NY...................................    18.5967    18.3428
Goldsboro, NC.....................................    19.4302    18.4900
Grand Forks, ND-MN................................    20.2317    19.5346
Grand Junction, CO................................    21.3486    20.1879
Grand Rapids-Muskegon-Holland, MI.................    22.4166    22.0645
Great Falls, MT...................................    19.7878    20.7979
Greeley, CO.......................................    21.1820    21.0411
Green Bay, WI.....................................    20.5432    19.9981
Greensboro-Winston-Salem-High Point, NC...........    21.2803    20.0780
Greenville, NC....................................    20.7237    20.4264
Greenville-Spartanburg-Anderson, SC...............    20.5626    19.8772
Hagerstown, MD....................................    18.6617    19.2372
Hamilton-Middletown, OH...........................    20.7196    19.8132
Harrisburg-Lebanon-Carlisle, PA...................    21.0273    20.8140
Hartford, CT......................................    25.7288    25.0922
Hattiesburg, MS...................................    16.6793    16.3839
Hickory-Morganton-Lenoir, NC......................    20.8978    19.9473
Honolulu, HI......................................    25.7427    25.2694
Houma, LA.........................................    17.7919    17.3205
Houston, TX.......................................    21.4873    20.8626
Huntington-Ashland, WV-KY-OH......................    21.4522    21.2133
Huntsville, AL....................................    19.8172    19.3336
Indianapolis, IN..................................    21.6359    21.2238
Iowa City, IA.....................................    21.9959    21.1012
Jackson, MI.......................................    20.6529    19.7626
Jackson, MS.......................................    18.9422    18.6455
Jackson, TN.......................................    20.1078    19.1864
Jacksonville, FL..................................    20.5769    19.8750
Jacksonville, NC..................................    17.0034    16.8680
Jamestown, NY.....................................    17.9583    17.1876

[[Page 40037]]

 
Janesville-Beloit, WI.............................    21.7281    20.9886
Jersey City, NJ...................................    24.9369    24.8965
Johnson City-Kingsport-Bristol, TN-VA.............    19.2235    18.6571
Johnstown, PA.....................................    19.4611    18.9954
Jonesboro, AR.....................................    18.7961    16.9923
Joplin, MO........................................    19.4696    17.8013
Kalamazoo-Battlecreek, MI.........................    23.7355    22.5300
Kankakee, IL......................................    22.0627    20.5487
Kansas City, KS-MO................................    21.2753    20.5840
Kenosha, WI.......................................    21.3454    20.4490
Killeen-Temple, TX................................    16.2682    19.9750
Knoxville, TN.....................................    19.8337    19.1504
Kokomo, IN........................................    20.3602    19.9881
La Crosse, WI-MN..................................    20.6365    19.8718
Lafayette, LA.....................................    19.0613    18.3994
Lafayette, IN.....................................    20.3481    19.3998
Lake Charles, LA..................................    17.3224    16.7485
Lakeland-Winter Haven, FL.........................    20.2272    19.6704
Lancaster, PA.....................................    20.7395    20.1687
Lansing-East Lansing, MI..........................    21.5357    21.4297
Laredo, TX........................................    17.5103    17.6390
Las Cruces, NM....................................    19.2336    18.7690
Las Vegas, NV-AZ..................................    24.9460    24.1211
\1\ Lawrence, KS..................................  .........    17.6233
Lawton, OK........................................    19.3702    19.7127
Lewiston-Auburn, ME...............................    20.7185    19.7537
Lexington, KY.....................................    19.6123    18.9899
Lima, OH..........................................    21.1268    20.0862
Lincoln, NE.......................................    22.6963    21.4133
Little Rock-North Little Rock, AR.................    19.9791    19.2054
Longview-Marshall, TX.............................    19.1225    19.0256
Los Angeles-Long Beach, CA........................    26.6548    26.0962
Louisville, KY-IN.................................    21.2596    20.4841
Lubbock, TX.......................................    18.8491    18.6166
Lynchburg, VA.....................................    20.3083    19.4241
Macon, GA.........................................    19.9824    19.2057
Madison, WI.......................................    23.0613    21.9843
Mansfield, OH.....................................    19.4276    18.7455
Mayaguez, PR......................................    10.8433    10.2295
McAllen-Edinburg-Mission, TX......................    18.6914    18.1962
Medford-Ashland, OR...............................    23.0097    22.6022
Melbourne-Titusville-Palm Bay, FL.................    22.1149    20.9722
Memphis, TN-AR-MS.................................    20.0303    18.8000
Merced, CA........................................    22.1904    21.6193
Miami, FL.........................................    22.1977    21.9246
Middlesex-Somerset-Hunterdon, NJ..................    25.5879    24.3992
Milwaukee-Waukesha, WI............................    22.2459    21.4514
Minneapolis-St. Paul, MN-WI.......................    24.3849    23.8437
Missoula, MT......................................    20.8911    20.0992
Mobile, AL........................................    18.0301    17.7727
Modesto, CA.......................................    24.1386    22.6578
Monmouth-Ocean, NJ................................    24.2514    24.2156
Monroe, LA........................................    18.2960    18.0030
Montgomery, AL....................................    16.4170    16.4651
Muncie, IN........................................    22.1725    22.9671
Myrtle Beach, SC..................................    19.5681    18.6951
Naples, FL........................................    21.6388    21.1816
Nashville, TN.....................................    21.7612    20.8163
Nassau-Suffolk, NY................................    30.4363    30.1896
New Haven-Bridgeport-Stamford-Waterbury-Danbury,      27.3029    26.7357
 CT...............................................
New London-Norwich, CT............................    25.7135    26.0913
New Orleans, LA...................................    20.1579    19.8724
New York, NY......................................    32.1854    31.5830
Newark, NJ........................................    25.9290    25.4360
Newburgh, NY-PA...................................    24.7917    23.8549
Norfolk-Virginia Beach-Newport News, VA-NC........    19.1397    18.4429
Oakland, CA.......................................    34.1768    32.8934
Ocala, FL.........................................    21.3185    20.6236
Odessa-Midland, TX................................    22.5425    20.4491
Oklahoma City, OK.................................    19.3952    18.9190
Olympia, WA.......................................    25.3219    23.8950
Omaha, NE-IA......................................    21.6670    21.5315
Orange County, CA.................................    24.8160    24.7793
Orlando, FL.......................................    21.5114    21.0699
Owensboro, KY.....................................    18.5923    17.8512
Panama City, FL...................................    20.2145    19.7652
Parkersburg-Marietta, WV-OH.......................    18.1448    17.9931
Pensacola, FL.....................................    18.6539    18.1053
Peoria-Pekin, IL..................................    19.5717    18.6727
Philadelphia, PA-NJ...............................    24.4217    23.9480
Phoenix-Mesa, AZ..................................    21.5030    20.8692
Pine Bluff, AR....................................    17.6144    16.9553
Pittsburgh, PA....................................    21.3283    20.9676
Pittsfield, MA....................................    22.9287    22.3291
Pocatello, ID.....................................    21.0779    19.9570
Ponce, PR.........................................    11.6402    11.0089
Portland, ME......................................    21.0314    20.7690
Portland-Vancouver, OR-WA.........................    24.7891    23.9331
Providence-Warwick, RI............................    24.1057    23.4709
Provo-Orem, UT....................................    21.9597    21.5577
Pueblo, CO........................................    19.1954    19.0481
Punta Gorda, FL...................................    20.1130    20.3995
Racine, WI........................................    20.8222    20.1696
Raleigh-Durham-Chapel Hill, NC....................    21.9030    21.0278
Rapid City, SD....................................    19.7860    18.9541
Reading, PA.......................................    21.3801    20.4191
Redding, CA.......................................    24.8864    24.7297
Reno, NV..........................................    23.2497    22.9230
Richland-Kennewick-Pasco, WA......................    24.4507    24.4034
Richmond-Petersburg, VA...........................    21.5917    20.8973
Riverside-San Bernardino, CA......................    24.7903    24.3425
Roanoke, VA.......................................    18.6747    18.3527
Rochester, MN.....................................    25.5712    24.8162
Rochester, NY.....................................    20.8521    20.0838
Rockford, IL......................................    20.5343    19.4475
Rocky Mount, NC...................................    20.3213    19.3679
Sacramento, CA....................................    26.3945    26.1465
Saginaw-Bay City-Midland, MI......................    21.3941    20.6362
St. Cloud, MN.....................................    21.9780    21.3047
\1\ St. Joseph, MO................................  .........    19.3531
St. Louis, MO-IL..................................    19.9244    19.5996
Salem, OR.........................................    22.3342    21.8859
Salinas, CA.......................................    32.7598    31.8419
Salt Lake City-Ogden, UT..........................    22.0030    21.4144
San Angelo, TX....................................    18.2784    17.4362
San Antonio, TX...................................    19.1516    18.4593
San Diego, CA.....................................    25.1307    25.3474
San Francisco, CA.................................    31.5450    30.6851
San Jose, CA......................................    31.6633    30.0720
San Juan-Bayamon, PR..............................    10.6229    10.2284
San Luis Obispo-Atascadero-Paso Robles, CA........    24.5182    23.3041
Santa Barbara-Santa Maria-Lompoc, CA..............    24.0983    23.3594
Santa Cruz-Watsonville, CA........................    31.1654    30.4145
Santa Fe, NM......................................    22.7435    22.5866
Santa Rosa, CA....................................    29.0793    28.0256
Sarasota-Bradenton, FL............................    22.5102    21.6154
Savannah, GA......................................    20.6199    20.9278
Scranton-Wilkes Barre-Hazleton, PA................    19.3713    18.4721
Seattle-Bellevue-Everett, WA......................    25.3458    24.3975
Sharon, PA........................................    17.6824    17.4957
Sheboygan, WI.....................................    18.7992    18.1442
Sherman-Denison, TX...............................    20.9115    19.8213
Shreveport-Bossier City, LA.......................    20.1898    19.4576
Sioux City, IA-NE.................................    19.5588    18.6963
Sioux Falls, SD...................................    20.3884    19.3356
South Bend, IN....................................    22.2935    21.5894
Spokane, WA.......................................    23.7995    23.1813
Springfield, IL...................................    19.3559    18.8869
Springfield, MO...................................    19.1121    18.1563
Springfield, MA...................................    24.2745    23.3313
State College, PA.................................    20.3757    19.7984
Steubenville-Weirton, OH-WV.......................    19.2689    18.6797
Stockton-Lodi, CA.................................    24.1271    23.2304
Sumter, SC........................................    17.3876    17.6174
Syracuse, NY......................................    21.4641    20.7071
Tacoma, WA........................................    25.9158    25.1530
Tallahassee, FL...................................    19.0232    18.5413
Tampa-St. Petersburg-Clearwater, FL...............    19.9114    19.5352
Terre Haute, IN...................................    19.0337    18.4440
Texarkana, AR-Texarkana, TX.......................    18.5780    17.9809
Toledo, OH........................................    21.8824    21.3504

[[Page 40038]]

 
Topeka, KS........................................    19.8816    19.8271
Trenton, NJ.......................................    23.2382    22.2118
Tucson, AZ........................................    20.0050    19.2367
Tulsa, OK.........................................    19.8607    18.4406
Tuscaloosa, AL....................................    18.2284    17.6510
Tyler, TX.........................................    21.5091    20.6026
Utica-Rome, NY....................................    18.5820    18.2679
Vallejo-Fairfield-Napa, CA........................    30.2552    28.8147
Ventura, CA.......................................    24.5276    24.2700
Victoria, TX......................................    18.5790    18.0303
Vineland-Millville-Bridgeton, NJ..................    23.2940    22.8113
Visalia-Tulare-Porterville, CA....................    21.4790    21.4191
Waco, TX..........................................    18.1355    17.7707
Washington, DC-MD-VA-WV...........................    24.4550    23.7621
Waterloo-Cedar Falls, IA..........................    17.9383    18.0820
Wausau, WI........................................    21.6311    20.7089
West Palm Beach-Boca Raton, FL....................    21.8130    21.3673
Wheeling, OH-WV...................................    17.8134    16.9419
Wichita, KS.......................................    21.4307    20.6976
Wichita Falls, TX.................................    17.5498    16.8374
Williamsport, PA..................................    19.2494    18.4198
Wilmington-Newark, DE-MD..........................    24.2660    24.1627
Wilmington, NC....................................    20.9901    20.6684
Yakima, WA........................................    23.5754    22.3174
Yolo, CA..........................................    21.6430    21.4983
York, PA..........................................    21.0635    20.3115
Youngstown-Warren, OH.............................    21.3343    21.0926
Yuba City, CA.....................................    23.1110    23.0076
Yuma, AZ..........................................    20.0535    20.5870
------------------------------------------------------------------------
\1\ The MSA is empty for FY 2002. The hospital(s) in the MSA received
  rural status under Section 401 of the Balanced Budget Refinement Act
  of 1999 (P.L. 106-113). The MSA is assigned the statewide rural wage
  index (see Table 4B).


   Table 3B.--FY 2002 and 3-Year* Average Hourly Wage for Rural Areas
[*Based on the sum of the salaries and hours computed for Federal Fiscal
                       years 2000, 2001, and 2002]
------------------------------------------------------------------------
                                                     FY 2002     3-Year
                                                     Average    Average
                   Nonurban Area                      Hourly     Hourly
                                                       Wage       Wage
------------------------------------------------------------------------
Alabama...........................................    16.3730    16.1146
Alaska............................................    26.4636    26.3425
Arizona...........................................    19.3673    18.5370
Arkansas..........................................    16.7079    16.0831
California........................................    21.5497    21.3758
Colorado..........................................    19.6575    19.2833
Connecticut.......................................    26.9422    26.2306
Delaware..........................................    21.3930    20.2349
Florida...........................................    19.6192    19.3651
Georgia...........................................    18.5057    17.9168
Hawaii............................................    24.7906    23.8356
Idaho.............................................    19.4497    18.9015
Illinois..........................................    17.9658    17.5928
Indiana...........................................    19.4553    18.6527
Iowa..............................................    18.1754    17.4857
Kansas............................................    17.4286    16.6018
Kentucky..........................................    17.7644    17.3603
Louisiana.........................................    16.9467    16.4424
Maine.............................................    19.4557    18.9537
Maryland..........................................    19.7644    18.9527
Massachusetts.....................................    25.5523    24.6681
Michigan..........................................    20.0792    19.4470
Minnesota.........................................    20.1570    19.2809
Mississippi.......................................    16.7955    16.1984
Missouri..........................................    17.6049    16.9330
Montana...........................................    19.3090    18.6615
Nebraska..........................................    18.1647    17.6040
Nevada............................................    21.6995    20.3605
New Hampshire.....................................    21.8156    21.4054
New Jersey \1\....................................  .........  .........
New Mexico........................................    19.3566    18.5498
New York..........................................    19.0675    18.6183
North Carolina....................................    19.0403    18.3332
North Dakota......................................    17.5784    16.8515
Ohio..............................................    19.3379    18.8488
Oklahoma..........................................    16.8803    16.1856
Oregon............................................    22.3705    21.7851
Pennsylvania......................................    19.2018    18.6374
Puerto Rico.......................................    10.7076     9.6394
Rhode Island \1\..................................  .........  .........
South Carolina....................................    18.9889    18.2492
South Dakota......................................    17.5369    16.6639
Tennessee.........................................    17.6873    16.9880
Texas.............................................    17.2050    16.4636
Utah..............................................    20.1916    19.5942
Vermont...........................................    21.1189    20.4055
Virginia..........................................    18.3851    17.6464
Washington........................................    22.7769    22.5424
West Virginia.....................................    17.9971    17.6684
Wisconsin.........................................    20.2251    19.3721
Wyoming...........................................    19.5145    19.1625
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                               Urban Areas
------------------------------------------------------------------------
                                                        Wage
         Urban Area  (Constituent Counties)             Index      GAF
------------------------------------------------------------------------
0040  Abilene, TX...................................    0.7983    0.8570
  Taylor, TX
0060  \2\ Aguadilla, PR.............................    0.4832    0.6077
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080  Akron, OH.....................................    0.9876    0.9915
  Portage, OH
  Summit, OH
0120  Albany, GA....................................    1.0640    1.0434
  Dougherty, GA
  Lee, GA
0160  \2\ Albany-Schenectady-Troy, NY...............    0.8547    0.8981
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200  Albuquerque, NM...............................    0.9750    0.9828
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220  Alexandria, LA................................    0.8059    0.8626
  Rapides, LA
0240  Allentown-Bethlehem-Easton, PA................    1.0077    1.0053
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280  Altoona, PA...................................    0.9126    0.9393
  Blair, PA
0320  Amarillo, TX..................................    0.8711    0.9098
  Potter, TX
  Randall, TX
0380  Anchorage, AK.................................    1.2696    1.1776
  Anchorage, AK
0440  Ann Arbor, MI.................................    1.1098    1.0739
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450  Anniston, AL..................................    0.8276    0.8785
  Calhoun, AL
0460  Appleton-Oshkosh-Neenah, WI...................    0.9241    0.9474
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470  \2\ Arecibo, PR...............................    0.4832    0.6077
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480  Asheville, NC.................................    0.9200    0.9445
  Buncombe, NC
  Madison, NC
0500  Athens, GA....................................    0.9842    0.9892
  Clarke, GA
  Madison, GA
  Oconee, GA
0520  \1\ Atlanta, GA...............................    1.0058    1.0040
  Barrow, GA
  Bartow, GA
  Carroll, GA
  Cherokee, GA
  Clayton, GA
  Cobb, GA
  Coweta, GA
  DeKalb, GA
  Douglas, GA
  Fayette, GA
  Forsyth, GA
  Fulton, GA
  Gwinnett, GA
  Henry, GA

[[Page 40039]]

 
  Newton, GA
  Paulding, GA
  Pickens, GA
  Rockdale, GA
  Spalding, GA
  Walton, GA
0560  Atlantic-Cape May, NJ.........................    1.1293    1.0868
  Atlantic, NJ
  Cape May, NJ
0580  Auburn-Opelika, AL............................    0.8230    0.8751
  Lee, AL
0600  Augusta-Aiken, GA-SC..........................    0.9970    0.9979
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640  \1\ Austin-San Marcos, TX.....................    0.9597    0.9722
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680  \2\ Bakersfield, CA...........................    0.9659    0.9765
  Kern, CA
0720  \1\ Baltimore, MD.............................    0.9856    0.9901
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733  Bangor, ME....................................    0.9593    0.9719
  Penobscot, ME
0743  Barnstable-Yarmouth, MA.......................    1.3626    1.2360
  Barnstable, MA
0760  Baton Rouge, LA...............................    0.8149    0.8692
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX......................    0.8442    0.8905
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860  Bellingham, WA................................    1.1826    1.1217
  Whatcom, WA
0870  \2\ Benton Harbor, MI.........................    0.9000    0.9304
  Berrien, MI
0875  \1\ Bergen-Passaic, NJ........................    1.1808    1.1205
  Bergen, NJ
  Passaic, NJ
0880  Billings, MT..................................    0.9352    0.9552
  Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS................    0.8440    0.8903
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960  \2\ Binghamton, NY............................    0.8547    0.8981
  Broome, NY
  Tioga, NY
1000  Birmingham, AL................................    0.8808    0.9168
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010  Bismarck, ND..................................    0.7984    0.8571
  Burleigh, ND
  Morton, ND
1020  Bloomington, IN...............................    0.8842    0.9192
  Monroe, IN
1040  Bloomington-Normal, IL........................    0.9038    0.9331
  McLean, IL
1080  Boise City, ID................................    0.9050    0.9339
  Ada, ID
  Canyon, ID
1123  \1\ \2\ Boston-Worcester-Lawrence-Lowell-         1.1454    1.0974
 Brockton, MA-NH (MA Hospitals).....................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH
  Rockingham, NH
  Strafford, NH
1123  \1\ Boston-Worcester-Lawrence-Lowell-Brockton,    1.1293    1.0868
 MA-NH (NH Hospitals)...............................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH
  Rockingham, NH
  Strafford, NH
1125  Boulder-Longmont, CO..........................    0.9799    0.9862
  Boulder, CO
1145  Brazoria, TX..................................    0.8209    0.8736
  Brazoria, TX
1150  Bremerton, WA.................................    1.0758    1.0513
  Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX..........    0.9012    0.9312
  Cameron, TX
1260  Bryan-College Station, TX.....................    0.9328    0.9535
  Brazos, TX
1280  \1\ Buffalo-Niagara Falls, NY.................    0.9459    0.9626
  Erie, NY
  Niagara, NY
1303  Burlington, VT................................    0.9883    0.9920
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310  \2\ Caguas, PR................................    0.4832    0.6077
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320  Canton-Massillon, OH..........................    0.8956    0.9273
  Carroll, OH
  Stark, OH
1350  Casper, WY....................................    0.9496    0.9652
  Natrona, WY
1360  Cedar Rapids, IA..............................    0.8699    0.9090
  Linn, IA
1400  Champaign-Urbana, IL..........................    0.9306    0.9519
  Champaign, IL
1440  Charleston-North Charleston, SC...............    0.9206    0.9449
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480  Charleston, WV................................    0.9264    0.9490
  Kanawha, WV
  Putnam, WV
1520  \1\ Charlotte-Gastonia-Rock Hill, NC-SC.......    0.9407    0.9590
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540  Charlottesville, VA...........................    1.0566    1.0384
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560  Chattanooga, TN-GA............................    0.9369    0.9563
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580  \2\ Cheyenne, WY..............................    0.8747    0.9124
  Laramie, WY
1600  \1\ Chicago, IL...............................    1.1046    1.0705
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL

[[Page 40040]]

 
  Will, IL
1620  Chico-Paradise, CA............................    0.9856    0.9901
  Butte, CA
1640  \1\ Cincinnati, OH-KY-IN......................    0.9473    0.9636
  Dearborn, IN
  Ohio, IN
  Boone, KY
  Campbell, KY
  Gallatin, KY
  Grant, KY
  Kenton, KY
  Pendleton, KY
  Brown, OH
  Clermont, OH
  Hamilton, OH
  Warren, OH
1660  Clarksville-Hopkinsville, TN-KY...............    0.8393    0.8869
  Christian, KY
  Montgomery, TN
1680  \1\ Cleveland-Lorain-Elyria, OH...............    0.9457    0.9625
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720  Colorado Springs, CO..........................    0.9744    0.9824
  El Paso, CO
1740  Columbia, MO..................................    0.8686    0.9080
  Boone, MO
1760  Columbia, SC..................................    0.9492    0.9649
  Lexington, SC
  Richland, SC
1800  Columbus, GA-AL...............................
  Russell, AL                                           0.8440    0.8903
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840  \1\ Columbus, OH..............................    0.9565    0.9700
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880  Corpus Christi, TX............................    0.8341    0.8832
  Nueces, TX
  San Patricio, TX
1890  Corvallis, OR.................................    1.1646    1.1100
  Benton, OR
1900  \2\ Cumberland, MD-WV (MD Hospitals)..........    0.8859    0.9204
  Allegany, MD
  Mineral, WV
1900  Cumberland, MD-WV (WV Hospital)...............    0.8306    0.8806
  Allegany, MD
  Mineral, WV
1920  \1\ Dallas, TX................................    0.9936    0.9956
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950  Danville, VA..................................    0.8613    0.9028
  Danville City, VA
  Pittsylvania, VA
1960  Davenport-Moline-Rock Island, IA-IL...........    0.8638    0.9046
  Scott, IA
  Henry, IL
  Rock Island, IL
2000  Dayton-Springfield, OH........................    0.9225    0.9463
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020  Daytona Beach, FL.............................    0.8972    0.9284
  Flagler, FL
  Volusia, FL
2030  Decatur, AL...................................    0.8775    0.9144
  Lawrence, AL
  Morgan, AL
2040  \2\ Decatur, IL...............................    0.8053    0.8622
  Macon, IL
2080  \1\ Denver, CO................................    1.0328    1.0223
  Adams, CO
  Arapahoe, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120  Des Moines, IA................................    0.8779    0.9147
  Dallas, IA
  Polk, IA
  Warren, IA
2160  \1\ Detroit, MI...............................    1.0487    1.0331
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180  Dothan, AL....................................    0.7988    0.8574
  Dale, AL
  Houston, AL
2190  Dover, DE.....................................    1.0296    1.0202
  Kent, DE
2200  Dubuque, IA...................................    0.8519    0.8960
  Dubuque, IA
2240  Duluth-Superior, MN-WI........................    1.0284    1.0194
  St. Louis, MN
  Douglas, WI
2281  Dutchess County, NY...........................    1.0532    1.0361
  Dutchess, NY
2290  \2\ Eau Claire, WI............................    0.9068    0.9352
  Chippewa, WI
  Eau Claire, WI
2320  El Paso, TX...................................    0.9215    0.9456
  El Paso, TX
2330  Elkhart-Goshen, IN............................    0.9638    0.9751
  Elkhart, IN
2335  \2\ Elmira, NY................................    0.8547    0.8981
  Chemung, NY
2340  Enid, OK......................................    0.8357    0.8843
  Garfield, OK
2360  Erie, PA......................................    0.8716    0.9102
  Erie, PA
2400  Eugene-Springfield, OR........................    1.1471    1.0985
  Lane, OR
2440  \2\ Evansville-Henderson, IN-KY (IN Hospitals)    0.8721    0.9105
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2440  Evansville-Henderson, IN-KY (KY Hospitals)....    0.8514    0.8957
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520  Fargo-Moorhead, ND-MN.........................    0.9267    0.9492
  Clay, MN
  Cass, ND
2560  Fayetteville, NC..............................    0.9027    0.9323
  Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR............    0.8445    0.8907
  Benton, AR
  Washington, AR
2620  Flagstaff, AZ-UT..............................    1.0556    1.0377
  Coconino, AZ
  Kane, UT
2640  Flint, MI.....................................    1.0913    1.0617
  Genesee, MI
2650  Florence, AL..................................    0.7889    0.8501
  Colbert, AL
  Lauderdale, AL
2655  Florence, SC..................................    0.8722    0.9106
  Florence, SC
2670  Fort Collins-Loveland, CO.....................    1.0045    1.0031
  Larimer, CO
2680  \1\ Ft. Lauderdale, FL........................    1.0784    1.0530
  Broward, FL
2700  Fort Myers-Cape Coral, FL.....................    0.9374    0.9567
  Lee, FL
2710  Fort Pierce-Port St. Lucie, FL................    1.0214    1.0146
  Martin, FL
  St. Lucie, FL
2720  Fort Smith, AR-OK.............................    0.8053    0.8622
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750  Fort Walton Beach, FL.........................    0.9002    0.9305

[[Page 40041]]

 
  Okaloosa, FL
2760  Fort Wayne, IN................................    0.9203    0.9447
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800  \1\ Fort Worth-Arlington, TX..................    0.9394    0.9581
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840  Fresno, CA....................................    0.9984    0.9989
  Fresno, CA
  Madera, CA
2880  Gadsden, AL...................................    0.8792    0.9156
  Etowah, AL
2900  Gainesville, FL...............................    0.9481    0.9642
  Alachua, FL
2920  Galveston-Texas City, TX......................    1.0313    1.0213
  Galveston, TX
2960  Gary, IN......................................    0.9530    0.9676
  Lake, IN
  Porter, IN
2975  \2\ Glens Falls, NY...........................    0.8547    0.8981
  Warren, NY
  Washington, NY
2980  Goldsboro, NC.................................    0.8709    0.9097
  Wayne, NC
2985  Grand Forks, ND-MN............................    0.9119    0.9388
  Polk, MN
  Grand Forks, ND
2995  Grand Junction, CO............................    0.9774    0.9845
  Mesa, CO
3000  \1\ Grand Rapids-Muskegon-Holland, MI.........    1.0048    1.0033
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040  Great Falls, MT...............................    0.9195    0.9441
  Cascade, MT
3060  Greeley, CO...................................    0.9495    0.9651
  Weld, CO
3080  Green Bay, WI.................................    0.9357    0.9555
  Brown, WI
3120  \1\ Greensboro-Winston-Salem-High Point, NC...    0.9539    0.9682
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NC
  Guilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150  Greenville, NC................................    0.9289    0.9507
  Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC...........    0.9217    0.9457
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180  \2\ Hagerstown, MD............................    0.8859    0.9204
  Washington, MD
3200  Hamilton-Middletown, OH.......................    0.9287    0.9506
  Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA...............    0.9425    0.9603
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283  \1\ \2\ Hartford, CT..........................    1.2077    1.1380
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285  \2\ Hattiesburg, MS...........................    0.7528    0.8233
  Forrest, MS
  Lamar, MS
3290  Hickory-Morganton-Lenoir, NC..................    0.9367    0.9562
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320  Honolulu, HI..................................    1.1544    1.1033
  Honolulu, HI
3350  Houma, LA.....................................    0.7975    0.8565
  Lafourche, LA
  Terrebonne, LA
3360  \1\ Houston, TX...............................    0.9631    0.9746
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400  Huntington-Ashland, WV-KY-OH..................    0.9616    0.9735
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440  Huntsville, AL................................    0.8883    0.9221
  Limestone, AL
  Madison, AL
3480  \1\ Indianapolis, IN..........................    0.9698    0.9792
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500  Iowa City, IA.................................    0.9859    0.9903
  Johnson, IA
3520  Jackson, MI...................................    0.9257    0.9485
  Jackson, MI
3560  Jackson, MS...................................    0.8491    0.8940
  Hinds, MS
  Madison, MS
  Rankin, MS
3580  Jackson, TN...................................    0.9013    0.9313
  Madison, TN
  Chester, TN
3600  \1\ Jacksonville, FL..........................    0.9223    0.9461
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605  \2\ Jacksonville, NC..........................    0.8535    0.8972
  Onslow, NC
3610  \2\ Jamestown, NY.............................    0.8547    0.8981
  Chautauqua, NY
3620  Janesville-Beloit, WI.........................    0.9739    0.9821
  Rock, WI
3640  Jersey City, NJ...............................    1.1178    1.0792
  Hudson, NJ
3660  Johnson City-Kingsport-Bristol, TN-VA.........    0.8617    0.9031
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680  Johnstown, PA.................................    0.8723    0.9107
  Cambria, PA
  Somerset, PA
3700  Jonesboro, AR.................................    0.8425    0.8893
  Craighead, AR
3710  Joplin, MO....................................    0.8727    0.9110
  Jasper, MO
  Newton, MO
3720  Kalamazoo-Battlecreek, MI.....................    1.0639    1.0433
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740  Kankakee, IL..................................    0.9889    0.9924
  Kankakee, IL
3760  \1\ Kansas City, KS-MO........................    0.9536    0.9680
  Johnson, KS
  Leavenworth, KS
  Miami, KS
  Wyandotte, KS
  Cass, MO
  Clay, MO
  Clinton, MO
  Jackson, MO
  Lafayette, MO
  Platte, MO
  Ray, MO
3800  Kenosha, WI...................................    0.9568    0.9702
  Kenosha, WI
3810  \2\ Killeen-Temple, TX........................    0.7714    0.8372

[[Page 40042]]

 
  Bell, TX
  Coryell, TX
3840  Knoxville, TN.................................    0.8890    0.9226
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850  Kokomo, IN....................................    0.9184    0.9434
  Howard, IN
  Tipton, IN
3870  La Crosse, WI-MN..............................    0.9250    0.9480
  Houston, MN
  La Crosse, WI
3880  Lafayette, LA.................................    0.8544    0.8978
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920  Lafayette, IN.................................    0.9121    0.9389
  Clinton, IN
  Tippecanoe, IN
3960  Lake Charles, LA..............................    0.7765    0.8409
  Calcasieu, LA
3980  Lakeland-Winter Haven, FL.....................    0.9067    0.9351
  Polk, FL
4000  Lancaster, PA.................................    0.9296    0.9512
  Lancaster, PA
4040  Lansing-East Lansing, MI......................    0.9653    0.9761
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080  Laredo, TX....................................    0.7849    0.8472
  Webb, TX
4100  \2\ Las Cruces, NM............................    0.8676    0.9073
  Dona Ana, NM
4120  \1\ Las Vegas, NV-AZ..........................    1.1182    1.0795
  Mohave, AZ
  Clark, NV
  Nye, NV
4150  Lawrence, KS..................................    0.7812    0.8444
  Douglas, KS
4200  Lawton, OK....................................    0.8682    0.9078
  Comanche, OK
4243  Lewiston-Auburn, ME...........................    0.9287    0.9506
  Androscoggin, ME
4280  Lexington, KY.................................    0.8791    0.9155
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320  Lima, OH......................................    0.9470    0.9634
  Allen, OH
  Auglaize, OH
4360  Lincoln, NE...................................    1.0173    1.0118
  Lancaster, NE
4400  Little Rock-North Little Rock, AR.............    0.8955    0.9272
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420  Longview-Marshall, TX.........................    0.8571    0.8998
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480  \1\ Los Angeles-Long Beach, CA................    1.1961    1.1305
  Los Angeles, CA
4520  \1\ Louisville, KY-IN.........................    0.9529    0.9675
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY
4600  Lubbock, TX...................................    0.8463    0.8920
  Lubbock, TX
4640  Lynchburg, VA.................................    0.9103    0.9377
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680  Macon, GA.....................................    0.8971    0.9283
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720  Madison, WI...................................    1.0367    1.0250
  Dane, WI
4800  Mansfield, OH.................................    0.8726    0.9109
  Crawford, OH
  Richland, OH
4840  Mayaguez, PR..................................    0.4860    0.6101
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880  McAllen-Edinburg-Mission, TX..................    0.8378    0.8859
  Hidalgo, TX
4890  Medford-Ashland, OR...........................    1.0314    1.0214
  Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.............    0.9913    0.9940
  Brevard, Fl
4920  \1\ Memphis, TN-AR-MS.........................    0.8978    0.9288
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940  Merced, CA....................................    0.9947    0.9964
  Merced, CA
5000  \1\ Miami, FL.................................    0.9950    0.9966
  Dade, FL
5015  \1\ Middlesex-Somerset-Hunterdon, NJ..........    1.1469    1.0984
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080  \1\ Milwaukee-Waukesha, WI....................    0.9971    0.9980
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120  \1\ Minneapolis-St. Paul, MN-WI...............    1.0930    1.0628
  Anoka, MN
  Carver, MN
  Chisago, MN
  Dakota, MN
  Hennepin, MN
  Isanti, MN
  Ramsey, MN
  Scott, MN
  Sherburne, MN
  Washington, MN
  Wright, MN
  Pierce, WI
  St. Croix, WI
5140  Missoula, MT..................................    0.9364    0.9560
  Missoula, MT
5160  Mobile, AL....................................    0.8084    0.8645
  Baldwin, AL
  Mobile, AL
5170  Modesto, CA...................................    1.0820    1.0555
  Stanislaus, CA
5190  \1\ Monmouth-Ocean, NJ........................    1.1257    1.0845
  Monmouth, NJ
  Ocean, NJ
5200  Monroe, LA....................................    0.8201    0.8730
  Ouachita, LA
5240  \2\ Montgomery, AL............................    0.7400    0.8137
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280  Muncie, IN....................................    0.9939    0.9958
  Delaware, IN
5330  Myrtle Beach, SC..............................    0.8771    0.9141
  Horry, SC
5345  Naples, FL....................................    0.9699    0.9793
  Collier, FL
5360  \1\ Nashville, TN.............................    0.9754    0.9831
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380  \1\ Nassau-Suffolk, NY........................    1.3643    1.2370
  Nassau, NY

[[Page 40043]]

 
  Suffolk, NY
5483  \1\ New Haven-Bridgeport-Stamford-Waterbury-..    1.2294    1.1519
  Danbury, CT
  Fairfield, CT
  New Haven, CT
5523  \2\ New London-Norwich, CT....................    1.2077    1.1380
  New London, CT
5560  \1\ New Orleans, LA...........................    0.9036    0.9329
  Jefferson, LA
  Orleans, LA
  Plaquemines, LA
  St. Bernard, LA
  St. Charles, LA
  St. James, LA
  St. John The Baptist, LA
  St. Tammany, LA
5600  \1\ New York, NY..............................    1.4427    1.2853
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640  \1\ Newark, NJ................................    1.1622    1.1084
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660  Newburgh, NY-PA...............................    1.1113    1.0749
  Orange, NY
  Pike, PA
5720  \1\ Norfolk-Virginia Beach-Newport News, VA-NC    0.8579    0.9004
  Currituck, NC
  Chesapeake City, VA
  Gloucester, VA
  Hampton City, VA
  Isle of Wight, VA
  James City, VA
  Mathews, VA
  Newport News City, VA
  Norfolk City, VA
  Poquoson City, VA
  Portsmouth City, VA
  Suffolk City, VA
  Virginia Beach City VA
  Williamsburg City, VA
  York, VA
5775  \1\ Oakland, CA...............................    1.5319    1.3392
  Alameda, CA
  Contra Costa, CA
5790  Ocala, FL.....................................    0.9556    0.9694
  Marion, FL
5800  Odessa-Midland, TX............................    1.0104    1.0071
  Ector, TX
  Midland, TX
5880  \1\ Oklahoma City, OK.........................    0.8694    0.9086
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910  Olympia, WA...................................    1.1350    1.0906
  Thurston, WA
5920  Omaha, NE-IA..................................    0.9712    0.9802
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945  \1\ Orange County, CA.........................    1.1246    1.0837
  Orange, CA
5960  \1\ Orlando, FL...............................    0.9642    0.9753
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990  Owensboro, KY.................................    0.8334    0.8827
  Daviess, KY
6015  Panama City, FL...............................    0.9061    0.9347
  Bay, FL
6020  Parkersburg-Marietta, WV-OH (WV Hospitals)....    0.8133    0.8680
  Washington, OH
  Wood, WV
6020  \2\ Parkersburg-Marietta, WV-OH (OH Hospitals)    0.8668    0.9067
  Washington, OH
  Wood, WV
6080  \2\ Pensacola, FL.............................    0.8794    0.9158
  Escambia, FL
  Santa Rosa, FL
6120  Peoria-Pekin, IL..............................    0.8773    0.9143
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160  \1\Philadelphia, PA-NJ........................    1.0947    1.0639
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200  \1\ Phoenix-Mesa, AZ..........................    0.9638    0.9751
  Maricopa, AZ
  Pinal, AZ
6240  Pine Bluff, AR................................    0.7895    0.8506
  Jefferson, AR
6280  \1\ Pittsburgh, PA............................    0.9560    0.9697
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323  \2\ Pittsfield, MA............................    1.1454    1.0974
  Berkshire, MA
6340  Pocatello, ID.................................    0.9448    0.9619
  Bannock, ID
6360  Ponce, PR.....................................    0.5218    0.6405
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403  Portland, ME..................................    0.9427    0.9604
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440  \1\ Portland-Vancouver, OR-WA.................    1.1150    1.0774
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483  \1\ Providence-Warwick-Pawtucket, RI..........    1.0805    1.0545
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520  Provo-Orem, UT................................    0.9843    0.9892
  Utah, UT
6560  \2\ Pueblo, CO................................    0.8811    0.9170
  Pueblo, CO
6580  Punta Gorda, FL...............................    0.9015    0.9315
  Charlotte, FL
6600  Racine, WI....................................    0.9333    0.9538
  Racine, WI
6640  \1\ Raleigh-Durham-Chapel Hill, NC............    0.9818    0.9875
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660  Rapid City, SD................................    0.8869    0.9211
  Pennington, SD
6680  Reading, PA...................................    0.9583    0.9713
  Berks, PA
6690  Redding, CA...................................    1.1155    1.0777
  Shasta, CA
6720  Reno, NV......................................    1.0421    1.0286
  Washoe, NV
6740  Richland-Kennewick-Pasco, WA..................    1.0960    1.0648
  Benton, WA
  Franklin, WA
6760  Richmond-Petersburg, VA.......................    0.9678    0.9778

[[Page 40044]]

 
  Charles City County, VA
  Chesterfield, VA
  Colonial Heights City, VA
  Dinwiddie, VA
  Goochland, VA
  Hanover, VA
  Henrico, VA
  Hopewell City, VA
  New Kent, VA
  Petersburg City, VA
  Powhatan, VA
  Prince George, VA
  Richmond City, VA
6780  \1\ Riverside-San Bernardino, CA..............    1.1112    1.0749
  Riverside, CA
  San Bernardino, CA
6800  Roanoke, VA...................................    0.8371    0.8854
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820  Rochester, MN.................................    1.1462    1.0979
  Olmsted, MN
6840  \1\ Rochester, NY.............................    0.9347    0.9548
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880  Rockford, IL..................................    0.9204    0.9448
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895  Rocky Mount, NC...............................    0.9109    0.9381
  Edgecombe, NC
  Nash, NC
6920  \1\ Sacramento, CA............................    1.1831    1.1220
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960  Saginaw-Bay City-Midland, MI..................    0.9590    0.9717
  Bay, MI
  Midland, MI
  Saginaw, MI
6980  St. Cloud, MN.................................    0.9919    0.9944
  Benton, MN
  Stearns, MN
7000  St. Joseph, MO................................    0.7899    0.8509
  Andrew, MO
  Buchanan, MO
7040  \1\ St. Louis, MO-IL..........................    0.8931    0.9255
  Clinton, IL
  Jersey, IL
  Madison, IL
  Monroe, IL
  St. Clair, IL
  Franklin, MO
  Jefferson, MO
  Lincoln, MO
  St. Charles, MO
  St. Louis, MO
  St. Louis City, MO
  Warren, MO
7080  \2\ Salem, OR.................................    1.0033    1.0023
  Marion, OR
  Polk, OR
7120  Salinas, CA...................................    1.4684    1.3009
  Monterey, CA
71601Salt Lake City-Ogden, UT.......................    0.9863    0.9906
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200  San Angelo, TX................................    0.8193    0.8724
  Tom Green, TX
7240  \1\ San Antonio, TX...........................    0.8584    0.9007
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320  \1\ San Diego, CA.............................    1.1265    1.0850
  San Diego, CA
7360  \1\ San Francisco, CA.........................    1.4140    1.2677
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400  \1\ San Jose, CA..............................    1.4193    1.2710
  Santa Clara, CA
7440  \1\ \2\ San Juan-Bayamon, PR..................    0.4832    0.6077
  Aguas Buenas, PR
  Barceloneta, PR
  Bayamon, PR
  Canovanas, PR
  Carolina, PR
  Catano, PR
  Ceiba, PR
  Comerio, PR
  Corozal, PR
  Dorado, PR
  Fajardo, PR
  Florida, PR
  Guaynabo, PR
  Humacao, PR
  Juncos, PR
  Los Piedras, PR
  Loiza, PR
  Luguillo, PR
  Manati, PR
  Morovis, PR
  Naguabo, PR
  Naranjito, PR
  Rio Grande, PR
  San Juan, PR
  Toa Alta, PR
  Toa Baja, PR
  Trujillo Alto, PR
  Vega Alta, PR
  Vega Baja, PR
  Yabucoa, PR
7460  San Luis Obispo-Atascadero-Paso Robles, CA....    1.0990    1.0668
  San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA..........    1.0802    1.0543
  Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA....................    1.3970    1.2573
  Santa Cruz, CA
7490  Santa Fe, NM..................................    1.0194    1.0132
  Los Alamos, NM
  Santa Fe, NM
7500   Santa Rosa, CA...............................    1.3034    1.1990
  Sonoma, CA
7510  Sarasota-Bradenton, FL........................    1.0090    1.0062
  Manatee, FL
  Sarasota, FL
7520  Savannah, GA..................................    0.9243    0.9475
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560  Scranton--Wilkes-Barre--Hazleton, PA..........    0.8683    0.9078
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600  \1\ Seattle-Bellevue-Everett, WA..............    1.1361    1.0913
  Island, WA
  King, WA
  Snohomish, WA
7610  \2\ Sharon, PA................................    0.8607    0.9024
  Mercer, PA
7620  \2\ Sheboygan, WI.............................    0.9068    0.9352
  Sheboygan, WI
7640  Sherman-Denison, TX...........................    0.9373    0.9566
  Grayson, TX
7680   Shreveport-Bossier City, LA..................    0.9050    0.9339
  Bossier, LA
  Caddo, LA
  Webster, LA
7720  Sioux City, IA-NE.............................    0.8767    0.9138
  Woodbury, IA
  Dakota, NE
7760  Sioux Falls, SD...............................    0.9139    0.9402
  Lincoln, SD
  Minnehaha, SD
7800  South Bend, IN................................    0.9993    0.9995
  St. Joseph, IN
7840  Spokane, WA...................................    1.0668    1.0453
  Spokane, WA
7880  Springfield, IL...............................    0.8676    0.9073
  Menard, IL
  Sangamon, IL
7920  Springfield, MO...............................    0.8567    0.8995
  Christian, MO
  Greene, MO
  Webster, MO
8003  \2\ Springfield, MA...........................    1.1454    1.0974
  Hampden, MA
  Hampshire, MA
8050  State College, PA.............................    0.9133    0.9398

[[Page 40045]]

 
  Centre, PA
8080  \2\ Steubenville-Weirton, OH-WV (OH Hospitals)    0.8668    0.9067
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8080  Steubenville-Weirton, OH-WV (WV Hospitals)....    0.8637    0.9045
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120  Stockton-Lodi, CA.............................    1.0988    1.0666
  San Joaquin, CA
8140  \2\ Sumter, SC................................    0.8512    0.8955
  Sumter, SC
8160  Syracuse, NY..................................    0.9621    0.9739
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200  Tacoma, WA....................................    1.1616    1.1080
  Pierce, WA
8240  \2\ Tallahassee, FL...........................    0.8794    0.9158
  Gadsden, FL
  Leon, FL
8280  \1\ Tampa-St. Petersburg-Clearwater, FL.......    0.8925    0.9251
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320  \2\ Terre Haute, IN...........................    0.8721    0.9105
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360  Texarkana,AR-Texarkana, TX....................    0.8327    0.8822
  Miller, AR
  Bowie, TX
8400  Toledo, OH....................................    0.9809    0.9869
  Fulton, OH
  Lucas, OH
  Wood, OH
8440  Topeka, KS....................................    0.8912    0.9242
  Shawnee, KS
8480   Trenton, NJ..................................    1.0416    1.0283
  Mercer, NJ
8520  Tucson, AZ....................................    0.8976    0.9287
  Pima, AZ
8560  Tulsa, OK.....................................    0.8902    0.9234
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600  Tuscaloosa, AL................................    0.8171    0.8708
  Tuscaloosa, AL
8640  Tyler, TX.....................................    0.9641    0.9753
  Smith, TX
8680  \2\ Utica-Rome, NY............................    0.8547    0.8981
  Herkimer, NY
  Oneida, NY
8720  Vallejo-Fairfield-Napa, CA....................    1.3562    1.2320
  Napa, CA
  Solano, CA
8735  Ventura, CA...................................    1.0994    1.0670
  Ventura, CA
8750  Victoria, TX..................................    0.8328    0.8822
  Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ..............    1.0441    1.0300
  Cumberland, NJ
8780  \2\ Visalia-Tulare-Porterville, CA............    0.9659    0.9765
  Tulare, CA
8800  Waco, TX......................................    0.8150    0.8693
  McLennan, TX
8840  \1\ Washington, DC-MD-VA-WV...................    1.0962    1.0649
  District of Columbia, DC
  Calvert, MD
  Charles, MD
  Frederick, MD
  Montgomery, MD
  Prince Georges, MD
  Alexandria City, VA
  Arlington, VA
  Clarke, VA
  Culpeper, VA
  Fairfax, VA
  Fairfax City, VA
  Falls Church City, VA
  Fauquier, VA
  Fredericksburg City, VA
  King George, VA
  Loudoun, VA
  Manassas City, VA
  Manassas Park City, VA
  Prince William, VA
  Spotsylvania, VA
  Stafford, VA
  Warren, VA
  Berkeley, WV
  Jefferson, WV
8920  Waterloo-Cedar Falls, IA......................    0.8677    0.9074
  Black Hawk, IA
8940  Wausau, WI....................................    0.9696    0.9791
  Marathon, WI
8960  \1\ West Palm Beach-Boca Raton, FL............    0.9777    0.9847
  Palm Beach, FL
9000  \2\ Wheeling, WV-OH (WV Hospitals)............    0.8067    0.8632
  Belmont, OH
  Marshall, WV
  Ohio, WV
9000  \2\ Wheeling, WV-OH (OH Hospitals)............    0.8668    0.9067
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040  Wichita, KS...................................    0.9606    0.9728
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080  Wichita Falls, TX.............................    0.7946    0.8543
  Archer, TX
  Wichita, TX
9140  Williamsport, PA..............................    0.8628    0.9039
  Lycoming, PA
9160  Wilmington-Newark, DE-MD......................    1.0877    1.0593
  New Castle, DE
  Cecil, MD
9200  Wilmington, NC................................    0.9409    0.9591
  New Hanover, NC
  Brunswick, NC
9260  Yakima, WA....................................    1.0567    1.0385
  Yakima, WA
9270  Yolo, CA......................................    0.9701    0.9794
  Yolo, CA
9280  York, PA......................................    0.9441    0.9614
  York, PA
9320  Youngstown-Warren, OH.........................    0.9563    0.9699
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340  Yuba City, CA.................................    1.0359    1.0244
  Sutter, CA
  Yuba, CA
9360  Yuma, AZ......................................    0.8989    0.9296
  Yuma, AZ
------------------------------------------------------------------------
\1\ Large Urban Area
\2\ Hospitals geographically located in the area are assigned the
  statewide rural wage index for FY 2002.


Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                               Rural Areas
------------------------------------------------------------------------
                                                        Wage
                    Nonurban Area                       Index      GAF
------------------------------------------------------------------------
Alabama.............................................    0.7400    0.8137
Alaska..............................................    1.1862    1.1240
Arizona.............................................    0.8681    0.9077
Arkansas............................................    0.7489    0.8204
California..........................................    0.9659    0.9765
Colorado............................................    0.8811    0.9170
Connecticut.........................................    1.2077    1.1380
Delaware............................................    0.9589    0.9717
Florida.............................................    0.8794    0.9158
Georgia.............................................    0.8295    0.8798
Hawaii..............................................    1.1112    1.0749
Idaho...............................................    0.8718    0.9103
Illinois............................................    0.8053    0.8622
Indiana.............................................    0.8721    0.9105
Iowa................................................    0.8147    0.8691
Kansas..............................................    0.7812    0.8444
Kentucky............................................    0.7963    0.8556
Louisiana...........................................    0.7692    0.8355
Maine...............................................    0.8721    0.9105
Maryland............................................    0.8859    0.9204
Massachusetts.......................................    1.1454    1.0974
Michigan............................................    0.9000    0.9304

[[Page 40046]]

 
Minnesota...........................................    0.9035    0.9329
Mississippi.........................................    0.7528    0.8233
Missouri............................................    0.7899    0.8509
Montana.............................................    0.8655    0.9058
Nebraska............................................    0.8142    0.8687
Nevada..............................................    0.9727    0.9812
New Hampshire.......................................    0.9779    0.9848
New Jersey \1\......................................  ........  ........
New Mexico..........................................    0.8676    0.9073
New York............................................    0.8547    0.8981
North Carolina......................................    0.8535    0.8972
North Dakota........................................    0.7879    0.8494
Ohio................................................    0.8668    0.9067
Oklahoma............................................    0.7566    0.8261
Oregon..............................................    1.0038    1.0026
Pennsylvania........................................    0.8607    0.9024
Puerto Rico.........................................    0.4832    0.6077
Rhode Island \1\....................................  ........  ........
South Carolina......................................    0.8512    0.8955
South Dakota........................................    0.7861    0.8481
Tennessee...........................................    0.7928    0.8530
Texas...............................................    0.7714    0.8372
Utah................................................    0.9051    0.9340
Vermont.............................................    0.9608    0.9730
Virginia............................................    0.8241    0.8759
Washington..........................................    1.0209    1.0143
West Virginia.......................................    0.8067    0.8632
Wisconsin...........................................    0.9068    0.9352
Wyoming.............................................    0.8747    0.9124
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                     Hospitals that are Reclassified
------------------------------------------------------------------------
                                                        Wage
                        Area                            Index      GAF
------------------------------------------------------------------------
Abilene, TX.........................................    0.7983    0.8570
Akron, OH...........................................    0.9876    0.9915
Albany, GA..........................................    1.0640    1.0434
Albuquerque, NM.....................................    0.9750    0.9828
Alexandria, LA......................................    0.8059    0.8626
Allentown-Bethlehem-Easton, PA......................    1.0077    1.0053
Altoona, PA.........................................    0.9126    0.9393
Amarillo, TX........................................    0.8502    0.8948
Anchorage, AK.......................................    1.2696    1.1776
Ann Arbor, MI.......................................    1.1098    1.0739
Anniston, AL........................................    0.7841    0.8466
Asheville, NC.......................................    0.9200    0.9445
Athens, GA..........................................    0.9706    0.9798
Atlanta, GA.........................................    1.0058    1.0040
Augusta-Aiken, GA-SC................................    0.9970    0.9979
Austin-San Marcos, TX...............................    0.9597    0.9722
Barnstable-Yarmouth, MA.............................    1.3423    1.2234
Baton Rouge, LA.....................................    0.8149    0.8692
Bellingham, WA......................................    1.1296    1.0870
Benton Harbor, MI...................................    0.9000    0.9304
Bergen-Passaic, NJ..................................    1.1808    1.1205
Billings, MT........................................    0.9352    0.9552
Biloxi-Gulfport-Pascagoula, MS......................    0.8105    0.8660
Binghamton, NY......................................    0.8607    0.9024
Birmingham, AL......................................    0.8808    0.9168
Bismarck, ND........................................    0.7984    0.8571
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH....    1.1293    1.0868
Burlington, VT (VT Hospitals).......................    0.9608    0.9730
Burlington, VT (NY Hospitals).......................    0.9606    0.9728
Caguas, PR..........................................    0.4832    0.6077
Casper, WY..........................................    0.9346    0.9547
Champaign-Urbana, IL................................    0.9140    0.9403
Charleston-North Charleston, SC.....................    0.9206    0.9449
Charleston, WV......................................    0.8902    0.9234
Charlotte-Gastonia-Rock Hill, NC-SC.................    0.9407    0.9590
Chattanooga, TN-GA..................................    0.9181    0.9432
Chicago, IL.........................................    1.0917    1.0619
Cincinnati, OH-KY-IN................................    0.9473    0.9636
Clarksville-Hopkinsville, TN-KY.....................    0.8393    0.8869
Cleveland-Lorain-Elyria, OH.........................    0.9457    0.9625
Columbia, MO........................................    0.8686    0.9080
Columbia, SC........................................    0.9168    0.9422
Columbus, GA-AL.....................................    0.8440    0.8903
Columbus, OH........................................    0.9565    0.9700
Corpus Christi, TX..................................    0.8238    0.8757
Dallas, TX..........................................    0.9936    0.9956
Davenport-Moline-Rock Island, IA-IL.................    0.8538    0.8974
Dayton-Springfield, OH..............................    0.9225    0.9463
Denver, CO..........................................    1.0328    1.0223
Des Moines, IA......................................    0.8779    0.9147
Dothan, AL..........................................    0.7988    0.8574
Dover, DE...........................................    1.0003    1.0002
Duluth-Superior, MN-WI..............................    1.0284    1.0194
Eau Claire, WI......................................    0.9068    0.9352
Elkhart-Goshen, IN..................................    0.9517    0.9667
Erie, PA............................................    0.8716    0.9102
Eugene-Springfield, OR..............................    1.1006    1.0678
Fargo-Moorhead, ND-MN...............................    0.9166    0.9421
Fayetteville, NC....................................    0.8869    0.9211
Flagstaff, AZ-UT....................................    1.0105    1.0072
Flint, MI...........................................    1.0810    1.0548
Florence, AL........................................    0.7889    0.8501
Florence, SC........................................    0.8722    0.9106
Fort Collins-Loveland, CO...........................    1.0045    1.0031
Ft. Lauderdale, FL..................................    1.0784    1.0530
Fort Pierce-Port St. Lucie, FL......................    1.0114    1.0078
Fort Smith, AR-OK...................................    0.7857    0.8478
Fort Walton Beach, FL...............................    0.8828    0.9182
Fort Wayne, IN......................................    0.9203    0.9447
Forth Worth-Arlington, TX...........................    0.9394    0.9581
Gadsden, AL.........................................    0.8386    0.8864
Gainesville, FL.....................................    0.9481    0.9642
Grand Forks, ND-MN..................................    0.9119    0.9388
Grand Junction, CO..................................    0.9774    0.9845
Grand Rapids-Muskegon-Holland, MI...................    0.9939    0.9958
Great Falls, MT.....................................    0.9195    0.9441
Greeley, CO.........................................    0.9495    0.9651
Green Bay, WI.......................................    0.9357    0.9555
Greensboro-Winston-Salem-High Point, NC.............    0.9395    0.9582
Greenville, NC......................................    0.9289    0.9507
Greenville-Spartanburg-Anderson, SC.................    0.9217    0.9457
Harrisburg-Lebanon-Carlisle, PA.....................    0.9425    0.9603
Hartford, CT........................................    1.1571    1.1051
Hattiesburg, MS.....................................    0.7528    0.8233
Hickory-Morganton-Lenoir, NC........................    0.9367    0.9562
Honolulu, HI........................................    1.1544    1.1033
Houston, TX.........................................    0.9631    0.9746
Huntington-Ashland, WV-KY-OH........................    0.9238    0.9472
Huntsville, AL......................................    0.8696    0.9088
Indianapolis, IN....................................    0.9698    0.9792
Iowa City, IA.......................................    0.9708    0.9799
Jackson, MS.........................................    0.8491    0.8940
Jackson, TN.........................................    0.8843    0.9192
Jacksonville, FL....................................    0.9223    0.9461
Johnson City-Kingsport-Bristol, TN-VA...............    0.8617    0.9031
Jonesboro, AR.......................................    0.8115    0.8667
Joplin, MO..........................................    0.8528    0.8967
Kalamazoo-Battlecreek, MI...........................    1.0471    1.0320
Kansas City, KS-MO..................................    0.9536    0.9680
Knoxville, TN.......................................    0.8890    0.9226
Kokomo, IN..........................................    0.9184    0.9434
Lafayette, LA.......................................    0.8395    0.8871
Lansing-East Lansing, MI............................    0.9653    0.9761
Las Vegas, NV-AZ....................................    1.1182    1.0795
Lawton, OK..........................................    0.8281    0.8788
Lexington, KY.......................................    0.8641    0.9048
Lima, OH............................................    0.9470    0.9634
Lincoln, NE.........................................    0.9843    0.9892
Little Rock-North Little Rock, AR...................    0.8800    0.9162
Longview-Marshall, TX...............................    0.8571    0.8998
Los Angeles-Long Beach, CA..........................    1.1961    1.1305
Louisville, KY-IN...................................    0.9416    0.9596
Lubbock, TX.........................................    0.8463    0.8920
Lynchburg, VA.......................................    0.8795    0.9158
Macon, GA...........................................    0.8971    0.9283
Madison, WI.........................................    1.0367    1.0250
Mansfield, OH.......................................    0.8726    0.9109
Medford-Ashland, OR.................................    1.0033    1.0023
Memphis, TN-AR-MS...................................    0.8793    0.9157
Miami, FL...........................................    0.9950    0.9966
Milwaukee-Waukesha, WI..............................    0.9865    0.9907
Minneapolis-St. Paul, MN-WI.........................    1.0930    1.0628
Missoula, MT........................................    0.9177    0.9429
Mobile, AL..........................................    0.8084    0.8645
Modesto, CA.........................................    1.0820    1.0555
Monmouth-Ocean, NJ..................................    1.1257    1.0845
Monroe, LA..........................................    0.8097    0.8654
Montgomery, AL......................................    0.7400    0.8137
Myrtle Beach, SC....................................    0.8577    0.9002

[[Page 40047]]

 
Nashville, TN.......................................    0.9552    0.9691
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.    1.2294    1.1519
New London-Norwich, CT..............................    1.1526    1.1021
New Orleans, LA.....................................    0.9036    0.9329
New York, NY........................................    1.4287    1.2767
Newark, NJ..........................................    1.1622    1.1084
Newburgh, NY-PA.....................................    1.0797    1.0539
Oakland, CA.........................................    1.5319    1.3392
Odessa-Midland, TX..................................    0.9495    0.9651
Oklahoma City, OK...................................    0.8694    0.9086
Omaha, NE-IA........................................    0.9712    0.9802
Orange County, CA...................................    1.1246    1.0837
Orlando, FL.........................................    0.9642    0.9753
Peoria-Pekin, IL....................................    0.8773    0.9143
Philadelphia, PA-NJ.................................    1.0947    1.0639
Pine Bluff, AR......................................    0.7895    0.8506
Pittsburgh, PA......................................    0.9419    0.9598
Pittsfield, MA......................................    0.9904    0.9934
Pocatello, ID.......................................    0.9159    0.9416
Portland, ME........................................    0.9427    0.9604
Portland-Vancouver, OR-WA...........................    1.1150    1.0774
Provo-Orem, UT......................................    0.9843    0.9892
Raleigh-Durham-Chapel Hill, NC......................    0.9818    0.9875
Rapid City, SD......................................    0.8869    0.9211
Reading, PA.........................................    0.9216    0.9456
Redding, CA.........................................    1.1155    1.0777
Reno, NV............................................    1.0421    1.0286
Richland-Kennewick-Pasco, WA........................    1.0356    1.0242
Richmond-Petersburg, VA.............................    0.9678    0.9778
Roanoke, VA.........................................    0.8371    0.8854
Rochester, MN.......................................    1.1462    1.0979
Rockford, IL........................................    0.9042    0.9334
Sacramento, CA......................................    1.1831    1.1220
Saginaw-Bay City-Midland, MI........................    0.9590    0.9717
St. Cloud, MN.......................................    0.9919    0.9944
St. Joseph, MO......................................    0.8121    0.8672
St. Louis, MO-IL....................................    0.8931    0.9255
Salinas, CA.........................................    1.4570    1.2940
Salt Lake City-Ogden, UT............................    0.9863    0.9906
San Diego, CA.......................................    1.1265    1.0850
Santa Fe, NM........................................    0.9765    0.9838
Santa Rosa, CA......................................    1.2631    1.1734
Sarasota-Bradenton, FL..............................    1.0090    1.0062
Savannah, GA........................................    0.9243    0.9475
Seattle-Bellevue-Everett, WA........................    1.1361    1.0913
Sherman-Denison, TX.................................    0.9003    0.9306
Shreveport-Bossier City, LA.........................    0.9050    0.9339
Sioux City, IA-NE...................................    0.8767    0.9138
Sioux Falls, SD.....................................    0.8939    0.9261
South Bend, IN......................................    0.9993    0.9995
Spokane, WA.........................................    1.0668    1.0453
Springfield, IL.....................................    0.8571    0.8998
Springfield, MO.....................................    0.8357    0.8843
Stockton-Lodi, CA...................................    1.0988    1.0666
Syracuse, NY........................................    0.9621    0.9739
Tampa-St. Petersburg-Clearwater, FL.................    0.8925    0.9251
Texarkana,AR-Texarkana, TX..........................    0.8327    0.8822
Toledo, OH..........................................    0.9809    0.9869
Topeka, KS..........................................    0.8749    0.9125
Tucson, AZ..........................................    0.8976    0.9287
Tulsa, OK...........................................    0.8760    0.9133
Tuscaloosa, AL......................................    0.8171    0.8708
Tyler, TX...........................................    0.9359    0.9556
Victoria, TX........................................    0.8328    0.8822
Waco, TX............................................    0.8150    0.8693
Washington, DC-MD-VA-WV.............................    1.0854    1.0577
Waterloo-Cedar Falls, IA............................    0.8677    0.9074
Wausau, WI..........................................    0.9558    0.9695
West Palm Beach-Boca Raton, FL......................    0.9777    0.9847
Wichita, KS.........................................    0.9237    0.9471
Wichita Falls, TX...................................    0.7946    0.8543
Wilmington-Newark, DE-MD............................    1.0877    1.0593
Rural Alabama.......................................    0.7528    0.8233
Rural Florida.......................................    0.8794    0.9158
Rural Illinois (IA Hospitals).......................    0.8147    0.8691
Rural Illinois (MO Hospitals).......................    0.8053    0.8622
Rural Kentucky......................................    0.7963    0.8556
Rural Louisiana.....................................    0.7692    0.8355
Rural Minnesota.....................................    0.9035    0.9329
Rural Missouri......................................    0.7899    0.8509
Rural Montana.......................................    0.8655    0.9058
Rural Nebraska......................................    0.8142    0.8687
Rural Nevada........................................    0.9161    0.9418
Rural Oregon........................................    1.0038    1.0026
Rural Texas.........................................    0.7714    0.8372
Rural Washington....................................    1.0209    1.0143
Rural Wisconsin.....................................    0.9068    0.9352
Rural Wyoming.......................................    0.8747    0.9124
------------------------------------------------------------------------


                Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
                                                                                            Wage
                                                                                          Index--       GAF--
                            Area                              Wage  Index      GAF        Reclass.     Reclass.
                                                                                         Hospitals    Hospitals
----------------------------------------------------------------------------------------------------------------
\1\ Aguadilla, PR...........................................       1.0025       1.0017  ...........  ...........
\1\ Arecibo, PR.............................................       1.0025       1.0017  ...........  ...........
\1\ Caguas, PR..............................................       1.0025       1.0017       1.0025       1.0017
Mayaguez, PR................................................       1.0084       1.0057  ...........  ...........
Ponce, PR...................................................       1.0825       1.0558  ...........  ...........
\1\ San Juan-Bayamon, PR....................................       1.0025       1.0017  ...........  ...........
Rural Puerto Rico...........................................       1.0025       1.0017  ...........  ...........
----------------------------------------------------------------------------------------------------------------
\1\ Hospitals geographically located in the area are assigned the Rural Puerto Rico wage index for FY 2002.


         Table 4G.--Pre-Reclassified Wage Index for Urban Areas
------------------------------------------------------------------------
                                                                  Wage
              Urban Area  (Constituent Counties)                  Index
------------------------------------------------------------------------
0040  Abilene, TX.............................................    0.7965
  Taylor, TX
0060  Aguadilla, PR...........................................    0.4683
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080  Akron, OH...............................................    0.9876
  Portage, OH
  Summit, OH
0120  Albany, GA..............................................    1.0640
  Dougherty, GA
  Lee, GA
0160  Albany-Schenectady-Troy, NY.............................    0.8500
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY

[[Page 40048]]

 
  Schenectady, NY
  Schoharie, NY
0200  Albuquerque, NM.........................................    0.9750
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220  Alexandria, LA..........................................    0.8029
  Rapides, LA
0240  Allentown-Bethlehem-Easton, PA..........................    1.0077
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280  Altoona, PA.............................................    0.9126
  Blair, PA
0320  Amarillo, TX............................................    0.8711
  Potter, TX
  Randall, TX
0380  Anchorage, AK...........................................    1.2570
  Anchorage, AK
0440  Ann Arbor, MI...........................................    1.1098
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450  Anniston, AL............................................    0.8276
  Calhoun, AL
0460  Appleton-Oshkosh-Neenah, WI.............................    0.9241
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470  Arecibo, PR.............................................    0.4630
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480  Asheville, NC...........................................    0.9200
  Buncombe, NC
  Madison, NC
0500  Athens, GA..............................................    0.9842
  Clarke, GA
  Madison, GA
  Oconee, GA
0520  Atlanta, GA.............................................    1.0058
  Barrow, GA
  Bartow, GA
  Carroll, GA
  Cherokee, GA
  Clayton, GA
  Cobb, GA
  Coweta, GA
  DeKalb, GA
  Douglas, GA
  Fayette, GA
  Forsyth, GA
  Fulton, GA
  Gwinnett, GA
  Henry, GA
  Newton, GA
  Paulding, GA
  Pickens, GA
  Rockdale, GA
  Spalding, GA
  Walton, GA
0560  Atlantic-Cape May, NJ...................................    1.1293
  Atlantic, NJ
  Cape May, NJ
0580  Auburn-Opelika, AL......................................    0.8230
  Lee, AL
0600  Augusta-Aiken, GA-SC....................................    0.9970
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640  Austin-San Marcos, TX...................................    0.9597
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680  Bakersfield, CA.........................................    0.9470
  Kern, CA
0720  Baltimore, MD...........................................    0.9856
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733  Bangor, ME..............................................    0.9593
  Penobscot, ME
0743  Barnstable-Yarmouth, MA.................................    1.3626
  Barnstable, MA
0760  Baton Rouge, LA.........................................    0.8149
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX................................    0.8442
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860  Bellingham, WA..........................................    1.1826
  Whatcom, WA
0870  Benton Harbor, MI.......................................    0.8810
  Berrien, MI
0875  Bergen-Passaic, NJ......................................    1.1689
  Bergen, NJ
  Passaic, NJ
0880  Billings, MT............................................    0.9352
  Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS..........................    0.8440
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960  Binghamton, NY..........................................    0.8446
  Broome, NY
  Tioga, NY
1000  Birmingham, AL..........................................    0.8808
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010  Bismarck, ND............................................    0.7984
  Burleigh, ND
  Morton, ND
1020  Bloomington, IN.........................................    0.8842
  Monroe, IN
1040  Bloomington-Normal, IL..................................    0.9038
  McLean, IL
1080  Boise City, ID..........................................    0.9050
  Ada, ID
  Canyon, ID
1123  Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH        1.1289
 Hospitals)...................................................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH
  Rockingham, NH
  Strafford, NH
1125  Boulder-Longmont, CO....................................    0.9799
  Boulder, CO
1145   Brazoria, TX...........................................    0.8209
  Brazoria, TX
1150  Bremerton, WA...........................................    1.0758
  Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX....................    0.9012
  Cameron, TX
1260  Bryan-College Station, TX...............................    0.9328
  Brazos, TX
1280  Buffalo-Niagara Falls, NY...............................    0.9459
  Erie, NY
  Niagara, NY
1303  Burlington, VT..........................................    0.9883
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310  Caguas, PR..............................................    0.4699
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320  Canton-Massillon, OH....................................    0.8956
  Carroll, OH
  Stark, OH
1350  Casper, WY..............................................    0.9496
  Natrona, WY
1360  Cedar Rapids, IA........................................    0.8699
  Linn, IA
1400  Champaign-Urbana, IL....................................    0.9306
  Champaign, IL
1440  Charleston-North Charleston, SC.........................    0.9206
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480  Charleston, WV..........................................    0.9264
  Kanawha, WV
  Putnam, WV
1520  Charlotte-Gastonia-Rock Hill, NC-SC.....................    0.9348
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540  Charlottesville, VA.....................................    1.0566
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560  Chattanooga, TN-GA......................................    0.9369
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN

[[Page 40049]]

 
  Marion, TN
1580  Cheyenne, WY............................................    0.8288
  Laramie, WY
1600  Chicago, IL.............................................    1.1046
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620  Chico-Paradise, CA......................................    0.9856
  Butte, CA
1640  Cincinnati, OH-KY-IN....................................    0.9473
  Dearborn, IN
  Ohio, IN
  Boone, KY
  Campbell, KY
  Gallatin, KY
  Grant, KY
  Kenton, KY
  Pendleton, KY
  Brown, OH
  Clermont, OH
  Hamilton, OH
  Warren, OH
1660  Clarksville-Hopkinsville, TN-KY.........................    0.8337
  Christian, KY
  Montgomery, TN
1680  Cleveland-Lorain-Elyria, OH.............................    0.9457
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720  Colorado Springs, CO....................................    0.9744
  El Paso, CO
1740  Columbia, MO............................................    0.8686
  Boone, MO
1760  Columbia, SC............................................    0.9492
  Lexington, SC
  Richland, SC
1800  Columbus, GA-ALRussell, AL..............................    0.8440
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840  Columbus, OH............................................    0.9565
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880  Corpus Christi, TX......................................    0.8341
  Nueces, TX
  San Patricio, TX
1890  Corvallis, OR...........................................    1.1646
  Benton, OR
1900  Cumberland, MD-WV (WV Hospital).........................    0.8306
  Allegany, MD
  Mineral, WV
1920  Dallas, TX..............................................    0.9936
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950  Danville, VA............................................    0.8613
  Danville City, VA
  Pittsylvania, VA
1960  Davenport-Moline-Rock Island, IA-IL.....................    0.8638
  Scott, IA
  Henry, IL
  Rock Island, IL
2000  Dayton-Springfield, OH..................................    0.9225
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020  Daytona Beach, FL.......................................    0.8982
  Flagler, FL
  Volusia, FL
2030  Decatur, AL.............................................    0.8775
  Lawrence, AL
  Morgan, AL
2040  Decatur, IL.............................................    0.7987
  Macon, IL
2080  Denver, CO..............................................    1.0328
  Adams, CO
  Arapahoe, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120  Des Moines, IA..........................................    0.8779
  Dallas, IA
  Polk, IA
  Warren, IA
2160  Detroit, MI.............................................    1.0487
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180  Dothan, AL..............................................    0.7948
  Dale, AL
  Houston, AL
2190  Dover, DE...............................................    1.0296
  Kent, DE
2200  Dubuque, IA.............................................    0.8519
  Dubuque, IA
2240  Duluth-Superior, MN-WI..................................    1.0284
  St. Louis, MN
  Douglas, WI
2281  Dutchess County, NY.....................................    1.0532
  Dutchess, NY
2290  Eau Claire, WI..........................................    0.8832
  Chippewa, WI
  Eau Claire, WI
2320  El Paso, TX.............................................    0.9215
  El Paso, TX
2330  Elkhart-Goshen, IN......................................    0.9638
  Elkhart, IN
2335  Elmira, NY..............................................    0.8415
  Chemung, NY
2340  Enid, OK................................................    0.8357
  Garfield, OK
2360  Erie, PA................................................    0.8716
  Erie, PA
2400  Eugene-Springfield, OR..................................    1.1471
  Lane, OR
2440  Evansville-Henderson, IN-KY (IN Hospitals)..............    0.8514
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520  Fargo-Moorhead, ND-MN...................................    0.9267
  Clay, MN
  Cass, ND
2560  Fayetteville, NC........................................    0.9027
  Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR......................    0.8445
  Benton, AR
  Washington, AR
2620  Flagstaff, AZ-UT........................................    1.0556
  Coconino, AZ
  Kane, UT
2640  Flint, MI...............................................    1.0913
  Genesee, MI
2650  Florence, AL............................................    0.7845
  Colbert, AL
  Lauderdale, AL
2655  Florence, SC............................................    0.8722
  Florence, SC
2670  Fort Collins-Loveland, CO...............................    1.0045
  Larimer, CO
2680  Ft. Lauderdale, FL......................................    1.0293
  Broward, FL
2700  Fort Myers-Cape Coral, FL...............................    0.9374
  Lee, FL
2710  Fort Pierce-Port St. Lucie, FL..........................    1.0214
  Martin, FL
  St. Lucie, FL
2720  Fort Smith, AR-OK.......................................    0.8053
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750  Fort Walton Beach, FL...................................    0.9002
  Okaloosa, FL
2760  Fort Wayne, IN..........................................    0.9203
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800  Forth Worth-Arlington, TX...............................    0.9394
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840  Fresno, CA..............................................    0.9887
  Fresno, CA
  Madera, CA
2880  Gadsden, AL.............................................
  Etowah, AL                                                      0.8792
2900  Gainesville, FL.........................................    0.9481
  Alachua, FL
2920  Galveston-Texas City, TX................................    1.0313
  Galveston, TX
2960  Gary, IN................................................    0.9530
  Lake, IN
  Porter, IN
2975  Glens Falls, NY.........................................    0.8336
  Warren, NY
  Washington, NY
2980  Goldsboro, NC...........................................    0.8709

[[Page 40050]]

 
  Wayne, NC
2985  Grand Forks, ND-MN......................................    0.9069
  Polk, MN
  Grand Forks, ND
2995  Grand Junction, CO......................................    0.9569
  Mesa, CO
3000  Grand Rapids-Muskegon-Holland, MI.......................    1.0048
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040  Great Falls, MT.........................................    0.8870
  Cascade, MT
3060  Greeley, CO.............................................    0.9495
  Weld, CO
3080  Green Bay, WI...........................................    0.9208
  Brown, WI
3120  Greensboro-Winston-Salem-High Point, NC.................    0.9539
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NC
  Guilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150  Greenville, NC..........................................    0.9289
  Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC.....................    0.9217
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180  Hagerstown, MD..........................................    0.8365
  Washington, MD
3200  Hamilton-Middletown, OH.................................    0.9287
  Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA.........................    0.9425
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283  Hartford, CT............................................    1.1533
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285  \2\ Hattiesburg, MS.....................................    0.7476
  Forrest, MS
  Lamar, MS
3290  Hickory-Morganton-Lenoir, NC............................    0.9367
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320  Honolulu, HI............................................    1.1539
  Honolulu, HI
3350  Houma, LA...............................................    0.7951
  Lafourche, LA
  Terrebonne, LA
3360  Houston, TX.............................................    0.9631
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400  Huntington-Ashland, WV-KY-OH............................    0.9616
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440  Huntsville, AL..........................................    0.8883
  Limestone, AL
  Madison, AL
3480  Indianapolis, IN........................................    0.9698
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500  Iowa City, IA...........................................    0.9859
  Johnson, IA
3520  Jackson, MI.............................................    0.9257
  Jackson, MI
3560  Jackson, MS.............................................    0.8491
  Hinds, MS
  Madison, MS
  Rankin, MS
3580  Jackson, TN.............................................    0.9013
  Madison, TN
  Chester, TN
3600  Jacksonville, FL........................................    0.9223
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605  Jacksonville, NC........................................    0.7622
  Onslow, NC
3610  Jamestown, NY...........................................    0.8050
  Chautauqua, NY
3620  Janesville-Beloit, WI...................................    0.9739
  Rock, WI
3640  Jersey City, NJ.........................................    1.1178
  Hudson, NJ
3660  Johnson City-Kingsport-Bristol, TN-VA...................    0.8617
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680  Johnstown, PA...........................................    0.8723
  Cambria, PA
  Somerset, PA
3700  Jonesboro, AR...........................................    0.8425
  Craighead, AR
3710  Joplin, MO..............................................    0.8727
  Jasper, MO
  Newton, MO
3720  Kalamazoo-Battlecreek, MI...............................    1.0639
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740  Kankakee, IL............................................    0.9889
  Kankakee, IL
3760  Kansas City, KS-MO......................................    0.9536
  Johnson, KS
  Leavenworth, KS
  Miami, KS
  Wyandotte, KS
  Cass, MO
  Clay, MO
  Clinton, MO
  Jackson, MO
  Lafayette, MO
  Platte, MO
  Ray, MO
3800  Kenosha, WI.............................................    0.9568
  Kenosha, WI
3810  Killeen-Temple, TX......................................    0.7292
  Bell, TX
  Coryell, TX
3840  Knoxville, TN...........................................    0.8890
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850  Kokomo, IN..............................................    0.9126
  Howard, IN
  Tipton, IN
3870  La Crosse, WI-MN........................................    0.9250
  Houston, MN
  La Crosse, WI
3880  Lafayette, LA...........................................    0.8526
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920  Lafayette, IN...........................................    0.9121
  Clinton, IN
  Tippecanoe, IN
3960  Lake Charles, LA........................................    0.7765
  Calcasieu, LA
3980  Lakeland-Winter Haven, FL...............................    0.9067
  Polk, FL
4000  Lancaster, PA...........................................    0.9296
  Lancaster, PA
4040  Lansing-East Lansing, MI................................    0.9653
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080  Laredo, TX..............................................    0.7849
  Webb, TX
4100  Las Cruces, NM..........................................    0.8621
  Dona Ana, NM
4120  Las Vegas, NV-AZ........................................    1.1182
  Mohave, AZ
  Clark, NV
  Nye, NV
4150  Lawrence, KS............................................    0.8656
  Douglas, KS
4200  Lawton, OK..............................................    0.8682
  Comanche, OK
4243  Lewiston-Auburn, ME.....................................    0.9287
  Androscoggin, ME
4280  Lexington, KY...........................................    0.8791
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY

[[Page 40051]]

 
  Scott, KY
  Woodford, KY
4320  Lima, OH................................................    0.9470
  Allen, OH
  Auglaize, OH
4360  Lincoln, NE.............................................    1.0173
  Lancaster, NE
4400  Little Rock-North Little Rock, AR.......................    0.8955
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420  Longview-Marshall, TX...................................    0.8571
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480  Los Angeles-Long Beach, CA..............................    1.1948
  Los Angeles, CA
4520  \1\ Louisville, KY-IN...................................    0.9529
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY
4600  Lubbock, TX.............................................    0.8449
  Lubbock, TX
4640  Lynchburg, VA...........................................    0.9103
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680  Macon, GA...............................................    0.8957
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720  Madison, WI.............................................    1.0337
  Dane, WI
4800  Mansfield, OH...........................................    0.8708
  Crawford, OH
  Richland, OH
4840  Mayaguez, PR............................................    0.4860
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880  McAllen-Edinburg-Mission, TX............................    0.8378
  Hidalgo, TX
4890   Medford-Ashland, OR....................................    1.0314
  Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.......................    0.9913
  Brevard, Fl
4920  Memphis, TN-AR-MS.......................................    0.8978
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940  Merced, CA..............................................    0.9757
  Merced, CA
5000  Miami, FL...............................................    0.9950
  Dade, FL
5015  Middlesex-Somerset-Hunterdon, NJ........................    1.1469
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080  Milwaukee-Waukesha, WI..................................    0.9971
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120  Minneapolis-St. Paul, MN-WI.............................    1.0930
  Anoka, MN
  Carver, MN
  Chisago, MN
  Dakota, MN
  Hennepin, MN
  Isanti, MN
  Ramsey, MN
  Scott, MN
  Sherburne, MN
  Washington, MN
  Wright, MN
  Pierce, WI
  St. Croix, WI
5140  Missoula, MT............................................    0.9364
  Missoula, MT
5160  Mobile, AL..............................................    0.8082
  Baldwin, AL
  Mobile, AL
5170  Modesto, CA.............................................    1.0820
  Stanislaus, CA
5190  Monmouth-Ocean, NJ......................................    1.0872
  Monmouth, NJ
  Ocean, NJ
5200  Monroe, LA..............................................    0.8201
  Ouachita, LA
5240  Montgomery, AL..........................................    0.7359
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280  Muncie, IN..............................................    0.9939
  Delaware, IN
5330  Myrtle Beach, SC........................................    0.8771
  Horry, SC
5345  Naples, FL..............................................    0.9699
  Collier, FL
5360  Nashville, TN...........................................    0.9754
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380  Nassau-Suffolk, NY......................................    1.3643
  Nassau, NY
  Suffolk, NY
5483  New Haven-Bridgeport-Stamford-Waterbury-................    1.2238
  Danbury, CT
  Fairfield, CT
  New Haven, CT
5523  New London-Norwich, CT..................................    1.1526
  New London, CT
5560  New Orleans, LA.........................................    0.9036
  Jefferson, LA
  Orleans, LA
  Plaquemines, LA
  St. Bernard, LA
  St. Charles, LA
  St. James, LA
  St. John The Baptist, LA
  St. Tammany, LA
5600  New York, NY............................................    1.4427
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640  Newark, NJ..............................................    1.1622
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660  Newburgh, NY-PA.........................................    1.1113
  Orange, NY
  Pike, PA
5720  Norfolk-Virginia Beach-Newport News, VA-NC..............    0.8579
  Currituck, NC
  Chesapeake City, VA
  Gloucester, VA
  Hampton City, VA
  Isle of Wight, VA
  James City, VA
  Mathews, VA
  Newport News City, VA
  Norfolk City, VA
  Poquoson City, VA
  Portsmouth City, VA
  Suffolk City, VA
  Virginia Beach City VA
  Williamsburg City, VA
  York, VA
5775  Oakland, CA.............................................    1.5319
  Alameda, CA
  Contra Costa, CA
5790  Ocala, FL...............................................    0.9556
  Marion, FL
5800  Odessa-Midland, TX......................................    1.0104
  Ector, TX
  Midland, TX
5880  Oklahoma City, OK.......................................    0.8694
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910   Olympia, WA............................................    1.1350
  Thurston, WA
5920  Omaha, NE-IA............................................    0.9712
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945  Orange County, CA.......................................    1.1123
  Orange, CA
5960  Orlando, FL.............................................    0.9642
  Lake, FL
  Orange, FL

[[Page 40052]]

 
  Osceola, FL
  Seminole, FL
5990  Owensboro, KY...........................................    0.8334
  Daviess, KY
6015   Panama City, FL........................................    0.9061
  Bay, FL
6020  Parkersburg-Marietta, WV-OH.............................    0.8133
  Washington, OH
  Wood, WV
6080  Pensacola, FL...........................................    0.8329
  Escambia, FL
  Santa Rosa, FL
6120  Peoria-Pekin, IL........................................    0.8773
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160  Philadelphia, PA-NJ.....................................    1.0947
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200  Phoenix-Mesa, AZ........................................    0.9638
  Maricopa, AZ
  Pinal, AZ
6240  Pine Bluff, AR..........................................    0.7895
  Jefferson, AR
6280  Pittsburgh, PA..........................................    0.9560
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323  Pittsfield, MA..........................................    1.0278
  Berkshire, MA
6340  Pocatello, ID...........................................    0.9448
  Bannock, ID
6360  Ponce, PR...............................................    0.5218
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403  Portland, ME............................................    0.9427
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440  Portland-Vancouver, OR-WA...............................    1.1111
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483  Providence-Warwick-Pawtucket, RI........................    1.0805
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520  Provo-Orem, UT..........................................    0.9843
  Utah, UT
6560  Pueblo, CO..............................................    0.8604
  Pueblo, CO
6580  Punta Gorda, FL.........................................    0.9015
  Charlotte, FL
6600  Racine, WI..............................................    0.9333
  Racine, WI
6640  Raleigh-Durham-Chapel Hill, NC..........................    0.9818
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660  Rapid City, SD..........................................    0.8869
  Pennington, SD
6680  Reading, PA.............................................    0.9583
  Berks, PA
6690  Redding, CA.............................................    1.1155
  Shasta, CA
6720  Reno, NV................................................    1.0440
  Washoe, NV
6740  Richland-Kennewick-Pasco, WA............................    1.0960
  Benton, WA
  Franklin, WA
6760  Richmond-Petersburg, VA.................................    0.9678
  Charles City County, VA
  Chesterfield, VA
  Colonial Heights City, VA
  Dinwiddie, VA
  Goochland, VA
  Hanover, VA
  Henrico, VA
  Hopewell City, VA
  New Kent, VA
  Petersburg City, VA
  Powhatan, VA
  Prince George, VA
  Richmond City, VA
6780  Riverside-San Bernardino, CA............................    1.1111
  Riverside, CA
  San Bernardino, CA
6800  Roanoke, VA.............................................    0.8371
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820  Rochester, MN...........................................    1.1462
  Olmsted, MN
6840  Rochester, NY...........................................    0.9347
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880  Rockford, IL............................................    0.9204
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895  Rocky Mount, NC.........................................    0.9109
  Edgecombe, NC
  Nash, NC
6920  Sacramento, CA..........................................    1.1831
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960  Saginaw-Bay City-Midland, MI............................    0.9590
  Bay, MI
  Midland, MI
  Saginaw, MI
6980  St. Cloud, MN...........................................    0.9851
  Benton, MN
  Stearns, MN
7000  St. Joseph, MO..........................................    0.9009
  Andrew, MO
  Buchanan, MO
7040  St. Louis, MO-IL........................................    0.8931
  Clinton, IL
  Jersey, IL
  Madison, IL
  Monroe, IL
  St. Clair, IL
  Franklin, MO
  Jefferson, MO
  Lincoln, MO
  St. Charles, MO
  St. Louis, MO
  St. Louis City, MO
  Warren, MO
7080  Salem, OR...............................................    1.0011
  Marion, OR
  Polk, OR
7120  Salinas, CA.............................................    1.4684
  Monterey, CA
7160  Salt Lake City-Ogden, UT................................    0.9863
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200  San Angelo, TX..........................................    0.8193
  Tom Green, TX
7240  San Antonio, TX.........................................    0.8584
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320  San Diego, CA...........................................    1.1265
  San Diego, CA
7360  San Francisco, CA.......................................    1.4140
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400  San Jose, CA............................................    1.4193
  Santa Clara, CA
7440  San Juan-Bayamon, PR....................................    0.4762
  Aguas Buenas, PR
  Barceloneta, PR
  Bayamon, PR
  Canovanas, PR
  Carolina, PR
  Catano, PR
  Ceiba, PR
  Comerio, PR
  Corozal, PR
  Dorado, PR
  Fajardo, PR
  Florida, PR
  Guaynabo, PR
  Humacao, PR
  Juncos, PR
  Los Piedras, PR
  Loiza, PR
  Luguillo, PR
  Manati, PR
  Morovis, PR
  Naguabo, PR

[[Page 40053]]

 
  Naranjito, PR
  Rio Grande, PR
  San Juan, PR
  Toa Alta, PR
  Toa Baja, PR
  Trujillo Alto, PR
  Vega Alta, PR
  Vega Baja, PR
  Yabucoa, PR
7460  San Luis Obispo-Atascadero-Paso Robles, CA..............    1.0990
  San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA....................    1.0802
  Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA..............................    1.3970
  Santa Cruz, CA
7490  Santa Fe, NM............................................    1.0194
  Los Alamos, NM
  Santa Fe, NM
7500   Santa Rosa, CA.........................................    1.3034
  Sonoma, CA
7510  Sarasota-Bradenton, FL..................................    1.0090
  Manatee, FL
  Sarasota, FL
7520  Savannah, GA............................................    0.9243
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560  Scranton--Wilkes-Barre--Hazleton, PA....................    0.8683
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600  Seattle-Bellevue-Everett, WA............................    1.1361
  Island, WA
  King, WA
  Snohomish, WA
7610  Sharon, PA..............................................    0.7926
  Mercer, PA
7620  Sheboygan, WI...........................................    0.8427
  Sheboygan, WI
7640  Sherman-Denison, TX.....................................    0.9373
  Grayson, TX
7680   Shreveport-Bossier City, LA............................    0.9050
  Bossier, LA
  Caddo, LA
  Webster, LA
7720  Sioux City, IA-NE.......................................    0.8767
  Woodbury, IA
  Dakota, NE
7760  Sioux Falls, SD.........................................    0.9139
  Lincoln, SD
  Minnehaha, SD
7800  South Bend, IN..........................................    0.9993
  St. Joseph, IN
7840  Spokane, WA.............................................    1.0668
  Spokane, WA
7880  Springfield, IL.........................................    0.8676
  Menard, IL
  Sangamon, IL
7920  Springfield, MO.........................................    0.8567
  Christian, MO
  Greene, MO
  Webster, MO
8003  Springfield, MA.........................................    1.0881
  Hampden, MA
  Hampshire, MA
8050  State College, PA.......................................    0.9133
  Centre, PA
8080  Steubenville-Weirton, OH-WV (WV Hospitals)..............    0.8637
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120  Stockton-Lodi, CA.......................................    1.0815
  San Joaquin, CA
8140  Sumter, SC..............................................    0.7794
  Sumter, SC
8160  Syracuse, NY............................................    0.9621
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200  Tacoma, WA..............................................    1.1616
  Pierce, WA
8240  Tallahassee, FL.........................................    0.8527
  Gadsden, FL
  Leon, FL
8280  Tampa-St. Petersburg-Clearwater, FL.....................    0.8925
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320  Terre Haute, IN.........................................    0.8532
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360  Texarkana,AR-Texarkana, TX..............................    0.8327
  Miller, AR
  Bowie, TX
8400  Toledo, OH..............................................    0.9809
  Fulton, OH
  Lucas, OH
  Wood, OH
8440  Topeka, KS..............................................    0.8912
  Shawnee, KS
8480   Trenton, NJ............................................    1.0416
  Mercer, NJ
8520  Tucson, AZ..............................................    0.8967
  Pima, AZ
8560  Tulsa, OK...............................................    0.8902
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600  Tuscaloosa, AL..........................................    0.8171
  Tuscaloosa, AL
8640  Tyler, TX...............................................    0.9641
  Smith, TX
8680  Utica-Rome, NY..........................................    0.8329
  Herkimer, NY
  Oneida, NY
8720  Vallejo-Fairfield-Napa, CA..............................    1.3562
  Napa, CA
  Solano, CA
8735  Ventura, CA.............................................    1.0994
  Ventura, CA
8750  Victoria, TX............................................    0.8328
  Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ........................    1.0441
  Cumberland, NJ
8780  Visalia-Tulare-Porterville, CA..........................    0.9610
  Tulare, CA
8800  Waco, TX................................................    0.8129
  McLennan, TX
8840  Washington, DC-MD-VA-WV.................................    1.0962
  District of Columbia, DC
  Calvert, MD
  Charles, MD
  Frederick, MD
  Montgomery, MD
  Prince Georges, MD
  Alexandria City, VA
  Arlington, VA
  Clarke, VA
  Culpeper, VA
  Fairfax, VA
  Fairfax City, VA
  Falls Church City, VA
  Fauquier, VA
  Fredericksburg City, VA
  King George, VA
  Loudoun, VA
  Manassas City, VA
  Manassas Park City, VA
  Prince William, VA
  Spotsylvania, VA
  Stafford, VA
  Warren, VA  Berkeley, WV
  Jefferson, WV
8920  Waterloo-Cedar Falls, IA................................    0.8041
  Black Hawk, IA
8940  Wausau, WI..............................................    0.9696
  Marathon, WI
8960  West Palm Beach-Boca Raton, FL..........................    0.9777
  Palm Beach, FL
9000  Wheeling, WV-OH.........................................    0.7985
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040  Wichita, KS.............................................    0.9606
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080  Wichita Falls, TX.......................................    0.7867
  Archer, TX
  Wichita, TX
9140  Williamsport, PA........................................    0.8521
  Lycoming, PA
9160  Wilmington-Newark, DE-MD................................    1.0877
  New Castle, DE
  Cecil, MD
9200  Wilmington, NC..........................................    0.9409
  New Hanover, NC
  Brunswick, NC
9260  Yakima, WA..............................................    1.0567
  Yakima, WA
9270  Yolo, CA................................................    0.9701
  Yolo, CA
9280  York, PA................................................    0.9441
  York, PA
9320  Youngstown-Warren, OH...................................    0.9563
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340  Yuba City, CA...........................................    1.0359
  Sutter, CA
  Yuba, CA
9360  Yuma, AZ................................................    0.8989
  Yuma, AZ
------------------------------------------------------------------------


[[Page 40054]]


         Table 4H.--Pre-Reclassified Wage Index for Rural Areas
------------------------------------------------------------------------
                                                                  Wage
                         Nonurban Area                            Index
------------------------------------------------------------------------
Alabama.......................................................    0.7339
Alaska........................................................    1.1862
Arizona.......................................................    0.8681
Arkansas......................................................    0.7489
California....................................................    0.9772
Colorado......................................................    0.8811
Connecticut...................................................    1.2077
Delaware......................................................    0.9589
Florida.......................................................    0.8812
Georgia.......................................................    0.8295
Hawaii........................................................    1.1112
Idaho.........................................................    0.8718
Illinois......................................................    0.8053
Indiana.......................................................    0.8721
Iowa..........................................................    0.8147
Kansas........................................................    0.7769
Kentucky......................................................    0.7963
Louisiana.....................................................    0.7601
Maine.........................................................    0.8721
Maryland......................................................    0.8859
Massachusetts.................................................    1.1454
Michigan......................................................    0.9010
Minnesota.....................................................    0.9035
Mississippi...................................................    0.7528
Missouri......................................................    0.7778
Montana.......................................................    0.8655
Nebraska......................................................    0.8142
Nevada........................................................    0.9673
New Hampshire.................................................    0.9803
New Jersey \1\................................................  ........
New Mexico....................................................    0.8676
New York......................................................    0.8547
North Carolina................................................    0.8539
North Dakota..................................................    0.7879
Ohio..........................................................    0.8668
Oklahoma......................................................    0.7566
Oregon........................................................    1.0027
Pennsylvania..................................................    0.8617
Puerto Rico...................................................    0.4800
Rhode Island \1\..............................................  ........
South Carolina................................................    0.8512
South Dakota..................................................    0.7861
Tennessee.....................................................    0.7928
Texas.........................................................    0.7712
Utah..........................................................    0.9051
Vermont.......................................................    0.9466
Virginia......................................................    0.8241
Washington....................................................    1.0209
West Virginia.................................................    0.8067
Wisconsin.....................................................    0.9079
Wyoming.......................................................    0.8747
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.

    --------------------
* Medicare data have been supplemented by data from 19 states for low 
volume DRGs.

** DRGs 469 and 470 contain cases which could not be assigned to valid 
DRGs.

Note: Geometric mean is used only to determine payment for transfer 
cases.

Note: Arithmetic mean is presented for informational purposes only.

Note: Relative weights are based on Medicare patient data and may not be 
appropriate for other patients.

[[Page 40054]]



  Table 5.--List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric and Arithmetic Mean
                                                 Length of Stay
----------------------------------------------------------------------------------------------------------------
                                                                               Relative    Geometric  Arithmetic
       DRG          MDC            Type                   DRG title             weights    mean LOS     mean LOS
----------------------------------------------------------------------------------------------------------------
1...............       01  SURG                  CRANIOTOMY AGE >17 EXCEPT        3.2713         7.6        10.2
                                                  FOR TRAUMA.
2...............       01  SURG                  CRANIOTOMY FOR TRAUMA AGE        3.3874         8.8        11.1
                                                  >17.
3...............       01  SURG                  *CRANIOTOMY AGE 0-17.......      1.9594        12.7        12.7
4...............       01  SURG                  SPINAL PROCEDURES..........      2.4148         5.5         8.1
5...............       01  SURG                  EXTRACRANIAL VASCULAR            1.3628         2.3         3.2
                                                  PROCEDURES.
6...............       01  SURG                  CARPAL TUNNEL RELEASE......       .7230         2.1         3.0
7...............       01  SURG                  PERIPH & CRANIAL NERVE &         2.6285         8.3        11.1
                                                  OTHER NERV SYST PROC W CC.
8...............       01  SURG                  PERIPH & CRANIAL NERVE &         1.3953         2.0         2.9
                                                  OTHER NERV SYST PROC W/O
                                                  CC.
9...............       01  MED                   SPINAL DISORDERS & INJURIES      1.3350         5.2         6.9
10..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W       1.2690         5.5         7.2
                                                  CC.
11..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W/       .8471         3.3         4.3
                                                  O CC.
12..............       01  MED                   DEGENERATIVE NERVOUS SYSTEM       .9020         4.9         6.3
                                                  DISORDERS.
13..............       01  MED                   MULTIPLE SCLEROSIS &              .8129         4.5         5.5
                                                  CEREBELLAR ATAXIA.
14..............       01  MED                   SPECIFIC CEREBROVASCULAR         1.1655         4.8         6.1
                                                  DISORDERS EXCEPT TIA.
15..............       01  MED                   TRANSIENT ISCHEMIC ATTACK &       .7349         3.0         3.7
                                                  PRECEREBRAL OCCLUSIONS.
16..............       01  MED                   NONSPECIFIC CEREBROVASCULAR      1.1867         5.1         6.5
                                                  DISORDERS W CC.
17..............       01  MED                   NONSPECIFIC CEREBROVASCULAR       .6689         2.7         3.4
                                                  DISORDERS W/O CC.
18..............       01  MED                   CRANIAL & PERIPHERAL NERVE        .9744         4.6         5.8
                                                  DISORDERS W CC.
19..............       01  MED                   CRANIAL & PERIPHERAL NERVE        .6756         3.0         3.8
                                                  DISORDERS W/O CC.
20..............       01  MED                   NERVOUS SYSTEM INFECTION         2.7764         9.0        11.4
                                                  EXCEPT VIRAL MENINGITIS.
21..............       01  MED                   VIRAL MENINGITIS...........      1.4573         5.5         7.1
22..............       01  MED                   HYPERTENSIVE ENCEPHALOPATHY      1.0037         4.0         5.1
23..............       01  MED                   NONTRAUMATIC STUPOR & COMA.       .8069         3.4         4.4
24..............       01  MED                   SEIZURE & HEADACHE AGE >17       1.0172         4.0         5.3
                                                  W CC.
25..............       01  MED                   SEIZURE & HEADACHE AGE >17        .5947         2.7         3.3
                                                  W/O CC.
26..............       01  MED                   SEIZURE & HEADACHE AGE 0-17       .5981         2.4         3.0
27..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3514         3.7         5.6
                                                  COMA >1 HR.
28..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3609         5.2         6.8
                                                  COMA 1 HR AGE >17 W CC.
29..............       01  MED                   TRAUMATIC STUPOR & COMA,          .6956         3.0         3.8
                                                  COMA 1 HR AGE >17 W/O CC.
30..............       01  MED                   *TRAUMATIC STUPOR & COMA,         .3314         2.0         2.0
                                                  COMA 1 HR AGE 0-17.
31..............       01  MED                   CONCUSSION AGE >17 W CC....       .9165         3.5         4.8
32..............       01  MED                   CONCUSSION AGE >17 W/O CC..       .5230         2.0         2.6
33..............       01  MED                   *CONCUSSION AGE 0-17.......       .2082         1.6         1.6
34..............       01  MED                   OTHER DISORDERS OF NERVOUS       1.0074         4.2         5.4
                                                  SYSTEM W CC.
35..............       01  MED                   OTHER DISORDERS OF NERVOUS        .5885         2.7         3.5
                                                  SYSTEM W/O CC.
36..............       02  SURG                  RETINAL PROCEDURES.........       .6615         1.2         1.5
37..............       02  SURG                  ORBITAL PROCEDURES.........      1.1300         2.9         4.3
38..............       02  SURG                  PRIMARY IRIS PROCEDURES....       .4751         2.0         2.6
39..............       02  SURG                  LENS PROCEDURES WITH OR           .5986         1.5         1.9
                                                  WITHOUT VITRECTOMY.
40..............       02  SURG                  EXTRAOCULAR PROCEDURES            .8264         2.4         3.6
                                                  EXCEPT ORBIT AGE >17.

[[Page 40055]]

 
41..............       02  SURG                  *EXTRAOCULAR PROCEDURES           .3374         1.6         1.6
                                                  EXCEPT ORBIT AGE 0-17.
42..............       02  SURG                  INTRAOCULAR PROCEDURES            .6302         1.6         2.3
                                                  EXCEPT RETINA, IRIS & LENS.
43..............       02  MED                   HYPHEMA....................       .4578         2.8         3.3
44..............       02  MED                   ACUTE MAJOR EYE INFECTIONS.       .6554         4.3         5.2
45..............       02  MED                   NEUROLOGICAL EYE DISORDERS.       .6760         2.7         3.3
46..............       02  MED                   OTHER DISORDERS OF THE EYE        .7962         3.9         5.0
                                                  AGE >17 W CC.
47..............       02  MED                   OTHER DISORDERS OF THE EYE        .5043         2.7         3.4
                                                  AGE >17 W/O CC.
48..............       02  MED                   *OTHER DISORDERS OF THE EYE       .2972         2.9         2.9
                                                  AGE 0-17.
49..............       03  SURG                  MAJOR HEAD & NECK                1.7649         3.8         5.1
                                                  PROCEDURES.
50..............       03  SURG                  SIALOADENECTOMY............       .8158         1.5         1.9
51..............       03  SURG                  SALIVARY GLAND PROCEDURES         .7895         1.8         2.7
                                                  EXCEPT SIALOADENECTOMY.
52..............       03  SURG                  CLEFT LIP & PALATE REPAIR..       .7590         1.5         1.9
53..............       03  SURG                  SINUS & MASTOID PROCEDURES       1.1773         2.3         3.7
                                                  AGE >17.
54..............       03  SURG                  *SINUS & MASTOID PROCEDURES       .4817         3.2         3.2
                                                  AGE 0-17.
55..............       03  SURG                  MISCELLANEOUS EAR, NOSE,          .8483         1.8         2.7
                                                  MOUTH & THROAT PROCEDURES.
56..............       03  SURG                  RHINOPLASTY................       .8787         2.0         2.7
57..............       03  SURG                  T&A PROC, EXCEPT                 1.2004         2.8         4.3
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE
                                                  >17.
58..............       03  SURG                  *T&A PROC, EXCEPT                 .2735         1.5         1.5
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
59..............       03  SURG                  TONSILLECTOMY &/OR                .8276         1.9         2.8
                                                  ADENOIDECTOMY ONLY, AGE
                                                  >17.
60..............       03  SURG                  *TONSILLECTOMY &/OR               .2083         1.5         1.5
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
61..............       03  SURG                  MYRINGOTOMY W TUBE               1.3541         3.3         5.7
                                                  INSERTION AGE >17.
62..............       03  SURG                  *MYRINGOTOMY W TUBE               .2950         1.3         1.3
                                                  INSERTION AGE 0-17.
63..............       03  SURG                  OTHER EAR, NOSE, MOUTH &         1.3718         3.3         4.7
                                                  THROAT O.R. PROCEDURES.
64..............       03  MED                   EAR, NOSE, MOUTH & THROAT        1.2319         4.8         6.8
                                                  MALIGNANCY.
65..............       03  MED                   DYSEQUILIBRIUM.............       .5326         2.4         2.9
66..............       03  MED                   EPISTAXIS..................       .5536         2.6         3.3
67..............       03  MED                   EPIGLOTTITIS...............       .7514         3.0         3.7
68..............       03  MED                   OTITIS MEDIA & URI AGE >17        .6665         3.6         4.3
                                                  W CC.
69..............       03  MED                   OTITIS MEDIA & URI AGE >17        .4948         2.8         3.4
                                                  W/O CC.
70..............       03  MED                   OTITIS MEDIA & URI AGE 0-17       .4575         2.5         3.0
71..............       03  MED                   LARYNGOTRACHEITIS..........       .6685         3.1         4.0
72..............       03  MED                   NASAL TRAUMA & DEFORMITY...       .6699         2.9         3.7
73..............       03  MED                   OTHER EAR, NOSE, MOUTH &          .7993         3.6         4.7
                                                  THROAT DIAGNOSES AGE >17.
74..............       03  MED                   *OTHER EAR, NOSE, MOUTH &         .3352         2.1         2.1
                                                  THROAT DIAGNOSES AGE 0-17.
75..............       04  SURG                  MAJOR CHEST PROCEDURES.....      3.2096         8.8        10.8
76..............       04  SURG                  OTHER RESP SYSTEM O.R.           3.0129        10.1        12.7
                                                  PROCEDURES W CC.
77..............       04  SURG                  OTHER RESP SYSTEM O.R.           1.2416         4.1         5.5
                                                  PROCEDURES W/O CC.
78..............       04  MED                   PULMONARY EMBOLISM.........      1.3295         6.3         7.2
79..............       04  MED                   RESPIRATORY INFECTIONS &         1.7094         7.6         9.3
                                                  INFLAMMATIONS AGE >17 W CC.
80..............       04  MED                   RESPIRATORY INFECTIONS &          .9215         5.0         6.0
                                                  INFLAMMATIONS AGE >17 W/O
                                                  CC.
81..............       04  MED                   *RESPIRATORY INFECTIONS &        1.5177         6.1         6.1
                                                  INFLAMMATIONS AGE 0-17.
82..............       04  MED                   RESPIRATORY NEOPLASMS......      1.4316         6.0         7.6
83..............       04  MED                   MAJOR CHEST TRAUMA W CC....       .9803         4.8         5.9
84..............       04  MED                   MAJOR CHEST TRAUMA W/O CC..       .5454         2.8         3.5
85..............       04  MED                   PLEURAL EFFUSION W CC......      1.2483         5.5         6.9
86..............       04  MED                   PLEURAL EFFUSION W/O CC....       .6769         3.0         3.8
87..............       04  MED                   PULMONARY EDEMA &                1.4282         5.5         6.9
                                                  RESPIRATORY FAILURE.
88..............       04  MED                   CHRONIC OBSTRUCTIVE               .9127         4.5         5.4
                                                  PULMONARY DISEASE.
89..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      1.0601         5.3         6.3
                                                  AGE >17 W CC.
90..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY       .6344         3.7         4.3
                                                  AGE >17 W/O CC.
91..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY       .7937         3.8         4.7
                                                  AGE 0-17.
92..............       04  MED                   INTERSTITIAL LUNG DISEASE W      1.2296         5.6         6.8
                                                  CC.
93..............       04  MED                   INTERSTITIAL LUNG DISEASE W/      .7443         3.5         4.3
                                                  O CC.
94..............       04  MED                   PNEUMOTHORAX W CC..........      1.2024         5.4         6.9
95..............       04  MED                   PNEUMOTHORAX W/O CC........       .5817         3.2         3.9
96..............       04  MED                   BRONCHITIS & ASTHMA AGE >17       .7604         4.1         4.9
                                                  W CC.
97..............       04  MED                   BRONCHITIS & ASTHMA AGE >17       .5636         3.2         3.8
                                                  W/O CC.
98..............       04  MED                   BRONCHITIS & ASTHMA AGE 0-        .7496         3.1         4.6
                                                  17.
99..............       04  MED                   RESPIRATORY SIGNS &               .6964         2.6         3.3
                                                  SYMPTOMS W CC.
100.............       04  MED                   RESPIRATORY SIGNS &               .5186         1.8         2.2
                                                  SYMPTOMS W/O CC.
101.............       04  MED                   OTHER RESPIRATORY SYSTEM          .8604         3.6         4.7
                                                  DIAGNOSES W CC.
102.............       04  MED                   OTHER RESPIRATORY SYSTEM          .5207         2.1         2.7
                                                  DIAGNOSES W/O CC.
103.............      PRE  SURG                  HEART TRANSPLANT...........     20.2413        39.2        58.5

[[Page 40056]]

 
104.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        7.8411        13.2        15.3
                                                  CARDIOTHORACIC PROC W CARD
                                                  CATH.
105.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        5.6796         8.8        10.4
                                                  CARDIOTHORACIC PROC W/O
                                                  CARD CATH.
106.............       05  SURG                  CORONARY BYPASS W PTCA.....      7.4396        10.7        12.3
107.............       05  SURG                  CORONARY BYPASS W CARDIAC        5.3125         9.7        10.9
                                                  CATH.
108.............       05  SURG                  OTHER CARDIOTHORACIC             5.5325         9.2        11.2
                                                  PROCEDURES.
109.............       05  SURG                  CORONARY BYPASS W/O PTCA OR      3.9017         7.0         8.0
                                                  CARDIAC CATH.
110.............       05  SURG                  MAJOR CARDIOVASCULAR             4.1576         8.1        10.3
                                                  PROCEDURES W CC.
111.............       05  SURG                  MAJOR CARDIOVASCULAR             2.2865         4.3         5.1
                                                  PROCEDURES W/O CC.
112.............       05  SURG                  NO LONGER VALID............       .0000          .0          .0
113.............       05  SURG                  AMPUTATION FOR CIRC SYSTEM       2.6714         9.8        12.9
                                                  DISORDERS EXCEPT UPPER
                                                  LIMB & TOE.
114.............       05  SURG                  UPPER LIMB & TOE AMPUTATION      1.6809         7.3         9.4
                                                  FOR CIRC SYSTEM DISORDERS.
115.............       05  SURG                  PRM CARD PACEM IMPL W            3.3822         7.2         9.2
                                                  AMI,HRT FAIL OR SHK,OR
                                                  AICD LEAD OR GN.
116.............       05  SURG                  OTHER PERMANENT CARDIAC          2.2648         3.6         4.9
                                                  PACEMAKER IMPLANT.
117.............       05  SURG                  CARDIAC PACEMAKER REVISION       1.3351         2.8         4.5
                                                  EXCEPT DEVICE REPLACEMENT.
118.............       05  SURG                  CARDIAC PACEMAKER DEVICE         1.4339         1.8         2.7
                                                  REPLACEMENT.
119.............       05  SURG                  VEIN LIGATION & STRIPPING..      1.3578         3.3         5.3
120.............       05  SURG                  OTHER CIRCULATORY SYSTEM         2.3552         6.7         9.9
                                                  O.R. PROCEDURES.
121.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.5787         5.6         6.9
                                                  & MAJOR COMP, DISCHARGED
                                                  ALIVE.
122.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.0241         3.2         3.9
                                                  W/O MAJOR COMP, DISCHARGED
                                                  ALIVE.
123.............       05  MED                   CIRCULATORY DISORDERS W          1.5883         3.2         5.0
                                                  AMI, EXPIRED.
124.............       05  MED                   CIRCULATORY DISORDERS            1.4072         3.6         4.6
                                                  EXCEPT AMI, W CARD CATH &
                                                  COMPLEX DIAG.
125.............       05  MED                   CIRCULATORY DISORDERS            1.0406         2.2         2.8
                                                  EXCEPT AMI, W CARD CATH W/
                                                  O COMPLEX DIAG.
126.............       05  MED                   ACUTE & SUBACUTE                 2.6836        10.5        13.0
                                                  ENDOCARDITIS.
127.............       05  MED                   HEART FAILURE & SHOCK......      1.0103         4.5         5.6
128.............       05  MED                   DEEP VEIN THROMBOPHLEBITIS.       .7320         5.2         5.9
129.............       05  MED                   CARDIAC ARREST, UNEXPLAINED      1.0209         1.7         2.8
130.............       05  MED                   PERIPHERAL VASCULAR               .9379         5.0         6.1
                                                  DISORDERS W CC.
131.............       05  MED                   PERIPHERAL VASCULAR               .5725         3.8         4.5
                                                  DISORDERS W/O CC.
132.............       05  MED                   ATHEROSCLEROSIS W CC.......       .6473         2.5         3.1
133.............       05  MED                   ATHEROSCLEROSIS W/O CC.....       .5558         1.9         2.3
134.............       05  MED                   HYPERTENSION...............       .5814         2.7         3.4
135.............       05  MED                   CARDIAC CONGENITAL &              .9128         3.7         4.8
                                                  VALVULAR DISORDERS AGE >17
                                                  W CC.
136.............       05  MED                   CARDIAC CONGENITAL &              .5643         2.2         2.8
                                                  VALVULAR DISORDERS AGE >17
                                                  W/O CC.
137.............       05  MED                   *CARDIAC CONGENITAL &             .8177         3.3         3.3
                                                  VALVULAR DISORDERS AGE 0-
                                                  17.
138.............       05  MED                   CARDIAC ARRHYTHMIA &              .8222         3.3         4.2
                                                  CONDUCTION DISORDERS W CC.
139.............       05  MED                   CARDIAC ARRHYTHMIA &              .4961         2.1         2.5
                                                  CONDUCTION DISORDERS W/O
                                                  CC.
140.............       05  MED                   ANGINA PECTORIS............       .5335         2.2         2.7
141.............       05  MED                   SYNCOPE & COLLAPSE W CC....       .7241         3.0         3.8
142.............       05  MED                   SYNCOPE & COLLAPSE W/O CC..       .5395         2.2         2.7
143.............       05  MED                   CHEST PAIN.................       .5191         1.7         2.1
144.............       05  MED                   OTHER CIRCULATORY SYSTEM         1.2015         4.3         5.8
                                                  DIAGNOSES W CC.
145.............       05  MED                   OTHER CIRCULATORY SYSTEM          .5899         2.2         2.8
                                                  DIAGNOSES W/O CC.
146.............       06  SURG                  RECTAL RESECTION W CC......      2.7764         9.6        10.9
147.............       06  SURG                  RECTAL RESECTION W/O CC....      1.5993         6.2         6.7
148.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        3.5332        11.1        13.1
                                                  PROCEDURES W CC.
149.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        1.5063         6.2         6.7
                                                  PROCEDURES W/O CC.
150.............       06  SURG                  PERITONEAL ADHESIOLYSIS W        2.9483        10.5        12.2
                                                  CC.
151.............       06  SURG                  PERITONEAL ADHESIOLYSIS W/O      1.3451         5.3         6.3
                                                  CC.
152.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.9477         7.4         8.7
                                                  PROCEDURES W CC.
153.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.1642         5.1         5.6
                                                  PROCEDURES W/O CC.
154.............       06  SURG                  STOMACH, ESOPHAGEAL &            4.3519        11.9        14.7
                                                  DUODENAL PROCEDURES AGE
                                                  >17 W CC.
155.............       06  SURG                  STOMACH, ESOPHAGEAL &            1.3273         3.4         4.5
                                                  DUODENAL PROCEDURES AGE
                                                  >17 W/O CC.
156.............       06  SURG                  *STOMACH, ESOPHAGEAL &            .8421         6.0         6.0
                                                  DUODENAL PROCEDURES AGE 0-
                                                  17.
157.............       06  SURG                  ANAL & STOMAL PROCEDURES W       1.2599         4.4         5.9
                                                  CC.
158.............       06  SURG                  ANAL & STOMAL PROCEDURES W/       .6209         2.0         2.5
                                                  O CC.

[[Page 40057]]

 
159.............       06  SURG                  HERNIA PROCEDURES EXCEPT         1.3618         4.2         5.4
                                                  INGUINAL & FEMORAL AGE >17
                                                  W CC.
160.............       06  SURG                  HERNIA PROCEDURES EXCEPT          .7655         2.2         2.7
                                                  INGUINAL & FEMORAL AGE >17
                                                  W/O CC.
161.............       06  SURG                  INGUINAL & FEMORAL HERNIA        1.1375         3.2         4.5
                                                  PROCEDURES AGE >17 W CC.
162.............       06  SURG                  INGUINAL & FEMORAL HERNIA         .6121         1.6         1.9
                                                  PROCEDURES AGE >17 W/O CC.
163.............       06  SURG                  *HERNIA PROCEDURES AGE 0-17       .6909         2.1         2.1
164.............       06  SURG                  APPENDECTOMY W COMPLICATED       2.3960         7.8         9.0
                                                  PRINCIPAL DIAG W CC.
165.............       06  SURG                  APPENDECTOMY W COMPLICATED       1.2904         4.5         5.0
                                                  PRINCIPAL DIAG W/O CC.
166.............       06  SURG                  APPENDECTOMY W/O                 1.4934         4.2         5.4
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W CC.
167.............       06  SURG                  APPENDECTOMY W/O                  .8753         2.2         2.6
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W/O CC.
168.............       03  SURG                  MOUTH PROCEDURES W CC......      1.2982         3.6         5.2
169.............       03  SURG                  MOUTH PROCEDURES W/O CC....       .6964         1.8         2.3
170.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      3.0540         9.4        12.5
                                                  PROCEDURES W CC.
171.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      1.1716         3.8         4.8
                                                  PROCEDURES W/O CC.
172.............       06  MED                   DIGESTIVE MALIGNANCY W CC..      1.3985         5.9         7.6
173.............       06  MED                   DIGESTIVE MALIGNANCY W/O CC       .6933         3.0         3.9
174.............       06  MED                   G.I. HEMORRHAGE W CC.......       .9896         4.1         5.1
175.............       06  MED                   G.I. HEMORRHAGE W/O CC.....       .5419         2.6         3.0
176.............       06  MED                   COMPLICATED PEPTIC ULCER...      1.0888         4.4         5.6
177.............       06  MED                   UNCOMPLICATED PEPTIC ULCER        .8910         3.9         4.8
                                                  W CC.
178.............       06  MED                   UNCOMPLICATED PEPTIC ULCER        .6408         2.7         3.2
                                                  W/O CC.
179.............       06  MED                   INFLAMMATORY BOWEL DISEASE.      1.0868         5.1         6.4
180.............       06  MED                   G.I. OBSTRUCTION W CC......       .9565         4.6         5.7
181.............       06  MED                   G.I. OBSTRUCTION W/O CC....       .5237         3.0         3.5
182.............       06  MED                   ESOPHAGITIS, GASTROENT &          .7940         3.6         4.6
                                                  MISC DIGEST DISORDERS AGE
                                                  >17 W CC.
183.............       06  MED                   ESOPHAGITIS, GASTROENT &          .5568         2.4         3.0
                                                  MISC DIGEST DISORDERS AGE
                                                  >17 W/O CC.
184.............       06  MED                   ESOPHAGITIS, GASTROENT &          .4141         2.5         3.0
                                                  MISC DIGEST DISORDERS AGE
                                                  0-17.
185.............       03  MED                   DENTAL & ORAL DIS EXCEPT          .8660         3.6         4.8
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE >17.
186.............       03  MED                   *DENTAL & ORAL DIS EXCEPT         .3210         2.9         2.9
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE 0-17.
187.............       03  MED                   DENTAL EXTRACTIONS &              .7868         3.2         4.2
                                                  RESTORATIONS.
188.............       06  MED                   OTHER DIGESTIVE SYSTEM           1.1250         4.6         6.0
                                                  DIAGNOSES AGE >17 W CC.
189.............       06  MED                   OTHER DIGESTIVE SYSTEM            .5776         2.5         3.3
                                                  DIAGNOSES AGE >17 W/O CC.
190.............       06  MED                   OTHER DIGESTIVE SYSTEM           1.1897         4.5         7.4
                                                  DIAGNOSES AGE 0-17.
191.............       07  SURG                  PANCREAS, LIVER & SHUNT          4.6199        12.2        15.5
                                                  PROCEDURES W CC.
192.............       07  SURG                  PANCREAS, LIVER & SHUNT          1.8255         6.0         7.1
                                                  PROCEDURES W/O CC.
193.............       07  SURG                  BILIARY TRACT PROC EXCEPT        3.5085        11.6        13.6
                                                  ONLY CHOLECYST W OR W/O
                                                  C.D.E. W CC.
194.............       07  SURG                  BILIARY TRACT PROC EXCEPT        1.7294         6.3         7.3
                                                  ONLY CHOLECYST W OR W/O
                                                  C.D.E. W/O CC.
195.............       07  SURG                  CHOLECYSTECTOMY W C.D.E. W       3.0863         9.4        10.9
                                                  CC.
196.............       07  SURG                  CHOLECYSTECTOMY W C.D.E. W/      1.6111         5.3         6.0
                                                  O CC.
197.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        2.5748         8.1         9.6
                                                  LAPAROSCOPE W/O C.D.E. W
                                                  CC.
198.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        1.2062         4.2         4.7
                                                  LAPAROSCOPE W/O C.D.E. W/O
                                                  CC.
199.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         2.5070         8.4        10.9
                                                  PROCEDURE FOR MALIGNANCY.
200.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         3.1811         8.5        12.0
                                                  PROCEDURE FOR NON-
                                                  MALIGNANCY.
201.............       07  SURG                  OTHER HEPATOBILIARY OR           3.7986        12.3        15.6
                                                  PANCREAS O.R. PROCEDURES.
202.............       07  MED                   CIRRHOSIS & ALCOHOLIC            1.3291         5.5         7.0
                                                  HEPATITIS.
203.............       07  MED                   MALIGNANCY OF HEPATOBILIARY      1.3627         5.7         7.3
                                                  SYSTEM OR PANCREAS.
204.............       07  MED                   DISORDERS OF PANCREAS            1.2047         4.9         6.2
                                                  EXCEPT MALIGNANCY.
205.............       07  MED                   DISORDERS OF LIVER EXCEPT        1.2207         5.2         6.7
                                                  MALIG,CIRR,ALC HEPA W CC.
206.............       07  MED                   DISORDERS OF LIVER EXCEPT         .7302         3.2         4.1
                                                  MALIG,CIRR,ALC HEPA W/O CC.
207.............       07  MED                   DISORDERS OF THE BILIARY         1.1120         4.3         5.5
                                                  TRACT W CC.
208.............       07  MED                   DISORDERS OF THE BILIARY          .6380         2.4         3.0
                                                  TRACT W/O CC.
209.............       08  SURG                  MAJOR JOINT & LIMB               1.9917         4.6         5.1
                                                  REATTACHMENT PROCEDURES OF
                                                  LOWER EXTREMITY.
210.............       08  SURG                  HIP & FEMUR PROCEDURES           1.7503         6.1         6.9
                                                  EXCEPT MAJOR JOINT AGE >17
                                                  W CC.

[[Page 40058]]

 
211.............       08  SURG                  HIP & FEMUR PROCEDURES           1.2236         4.6         5.0
                                                  EXCEPT MAJOR JOINT AGE >17
                                                  W/O CC.
212.............       08  SURG                  *HIP & FEMUR PROCEDURES           .8457        11.1        11.1
                                                  EXCEPT MAJOR JOINT AGE 0-
                                                  17.
213.............       08  SURG                  AMPUTATION FOR                   1.9437         7.7        10.0
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE DISORDERS.
214.............       08  SURG                  NO LONGER VALID............       .0000          .0          .0
215.............       08  SURG                  NO LONGER VALID............       .0000          .0          .0
216.............       08  SURG                  BIOPSIES OF MUSCULOSKELETAL      2.3172         8.5        10.9
                                                  SYSTEM & CONNECTIVE TISSUE.
217.............       08  SURG                  WND DEBRID & SKN GRFT            3.2005        11.0        15.2
                                                  EXCEPT HAND,FOR MUSCSKELET
                                                  & CONN TISS DIS.
218.............       08  SURG                  LOWER EXTREM & HUMER PROC        1.5499         4.7         5.8
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  >17 W CC.
219.............       08  SURG                  LOWER EXTREM & HUMER PROC         .9950         2.8         3.3
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  >17 W/O CC.
220.............       08  SURG                  *LOWER EXTREM & HUMER PROC        .5834         5.3         5.3
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  0-17.
221.............       08  SURG                  NO LONGER VALID............       .0000          .0          .0
222.............       08  SURG                  NO LONGER VALID............       .0000          .0          .0
223.............       08  SURG                  MAJOR SHOULDER/ELBOW PROC,        .9723         2.1         2.9
                                                  OR OTHER UPPER EXTREMITY
                                                  PROC W CC.
224.............       08  SURG                  SHOULDER,ELBOW OR FOREARM         .7697         1.6         1.9
                                                  PROC,EXC MAJOR JOINT PROC,
                                                  W/O CC.
225.............       08  SURG                  FOOT PROCEDURES............      1.1164         3.8         5.3
226.............       08  SURG                  SOFT TISSUE PROCEDURES W CC      1.5902         5.2         7.3
227.............       08  SURG                  SOFT TISSUE PROCEDURES W/O        .7922         2.1         2.7
                                                  CC.
228.............       08  SURG                  MAJOR THUMB OR JOINT             1.0906         2.7         4.0
                                                  PROC,OR OTH HAND OR WRIST
                                                  PROC W CC.
229.............       08  SURG                  HAND OR WRIST PROC, EXCEPT        .7142         1.9         2.5
                                                  MAJOR JOINT PROC, W/O CC.
230.............       08  SURG                  LOCAL EXCISION & REMOVAL OF      1.3598         3.9         5.8
                                                  INT FIX DEVICES OF HIP &
                                                  FEMUR.
231.............       08  SURG                  LOCAL EXCISION & REMOVAL OF      1.4340         3.6         5.4
                                                  INT FIX DEVICES EXCEPT HIP
                                                  & FEMUR.
232.............       08  SURG                  ARTHROSCOPY................       .9532         1.8         2.9
233.............       08  SURG                  OTHER MUSCULOSKELET SYS &        2.0945         6.3         8.4
                                                  CONN TISS O.R. PROC W CC.
234.............       08  SURG                  OTHER MUSCULOSKELET SYS &        1.2097         2.7         3.6
                                                  CONN TISS O.R. PROC W/O CC.
235.............       08  MED                   FRACTURES OF FEMUR.........       .7632         4.1         5.5
236.............       08  MED                   FRACTURES OF HIP & PELVIS..       .6889         3.9         4.9
237.............       08  MED                   SPRAINS, STRAINS, &               .5325         3.0         3.6
                                                  DISLOCATIONS OF HIP,
                                                  PELVIS & THIGH.
238.............       08  MED                   OSTEOMYELITIS..............      1.4154         7.4         9.4
239.............       08  MED                   PATHOLOGICAL FRACTURES &         1.0032         5.4         6.7
                                                  MUSCULOSKELETAL & CONN
                                                  TISS MALIGNANCY.
240.............       08  MED                   CONNECTIVE TISSUE DISORDERS      1.3692         5.6         7.3
                                                  W CC.
241.............       08  MED                   CONNECTIVE TISSUE DISORDERS       .6315         3.3         4.0
                                                  W/O CC.
242.............       08  MED                   SEPTIC ARTHRITIS...........      1.0953         5.7         7.2
243.............       08  MED                   MEDICAL BACK PROBLEMS......       .7304         4.0         4.9
244.............       08  MED                   BONE DISEASES & SPECIFIC          .7152         4.1         5.1
                                                  ARTHROPATHIES W CC.
245.............       08  MED                   BONE DISEASES & SPECIFIC          .4665         2.9         3.6
                                                  ARTHROPATHIES W/O CC.
246.............       08  MED                   NON-SPECIFIC ARTHROPATHIES.       .5717         3.2         4.1
247.............       08  MED                   SIGNS & SYMPTOMS OF               .5587         2.8         3.6
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE.
248.............       08  MED                   TENDONITIS, MYOSITIS &            .8160         4.1         5.1
                                                  BURSITIS.
249.............       08  MED                   AFTERCARE, MUSCULOSKELETAL        .6784         2.7         3.9
                                                  SYSTEM & CONNECTIVE TISSUE.
250.............       08  MED                   FX, SPRN, STRN & DISL OF          .6809         3.5         4.3
                                                  FOREARM, HAND, FOOT AGE
                                                  >17 W CC.
251.............       08  MED                   FX, SPRN, STRN & DISL OF          .4582         2.4         2.9
                                                  FOREARM, HAND, FOOT AGE
                                                  >17 W/O CC.
252.............       08  MED                   *FX, SPRN, STRN & DISL OF         .2533         1.8         1.8
                                                  FOREARM, HAND, FOOT AGE 0-
                                                  17.
253.............       08  MED                   FX, SPRN, STRN & DISL OF          .7397         4.0         5.0
                                                  UPARM,LOWLEG EX FOOT AGE
                                                  >17 W CC.
254.............       08  MED                   FX, SPRN, STRN & DISL OF          .4294         2.8         3.3
                                                  UPARM,LOWLEG EX FOOT AGE
                                                  >17 W/O CC.
255.............       08  MED                   *FX, SPRN, STRN & DISL OF         .2951         2.9         2.9
                                                  UPARM,LOWLEG EX FOOT AGE 0-
                                                  17.
256.............       08  MED                   OTHER MUSCULOSKELETAL             .8152         4.2         5.4
                                                  SYSTEM & CONNECTIVE TISSUE
                                                  DIAGNOSES.

[[Page 40059]]

 
257.............       09  SURG                  TOTAL MASTECTOMY FOR              .8783         2.2         2.8
                                                  MALIGNANCY W CC.
258.............       09  SURG                  TOTAL MASTECTOMY FOR              .6954         1.7         1.9
                                                  MALIGNANCY W/O CC.
259.............       09  SURG                  SUBTOTAL MASTECTOMY FOR           .8763         1.8         2.7
                                                  MALIGNANCY W CC.
260.............       09  SURG                  SUBTOTAL MASTECTOMY FOR           .6435         1.3         1.4
                                                  MALIGNANCY W/O CC.
261.............       09  SURG                  BREAST PROC FOR NON-              .9240         1.7         2.3
                                                  MALIGNANCY EXCEPT BIOPSY &
                                                  LOCAL EXCISION.
262.............       09  SURG                  BREAST BIOPSY & LOCAL             .8487         3.0         4.3
                                                  EXCISION FOR NON-
                                                  MALIGNANCY.
263.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       2.0570         9.1        12.3
                                                  SKN ULCER OR CELLULITIS W
                                                  CC.
264.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       1.1079         5.6         7.3
                                                  SKN ULCER OR CELLULITIS W/
                                                  O CC.
265.............       09  SURG                  SKIN GRAFT &/OR DEBRID           1.6795         5.2         7.6
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W CC.
266.............       09  SURG                  SKIN GRAFT &/OR DEBRID            .8414         2.4         3.4
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W/O CC.
267.............       09  SURG                  PERIANAL & PILONIDAL              .9406         3.3         4.5
                                                  PROCEDURES.
268.............       09  SURG                  SKIN, SUBCUTANEOUS TISSUE &      1.2368         2.5         3.7
                                                  BREAST PLASTIC PROCEDURES.
269.............       09  SURG                  OTHER SKIN, SUBCUT TISS &        1.7731         6.9         9.2
                                                  BREAST PROC W CC.
270.............       09  SURG                  OTHER SKIN, SUBCUT TISS &         .7806         2.5         3.6
                                                  BREAST PROC W/O CC.
271.............       09  MED                   SKIN ULCERS................      1.0365         6.2         7.7
272.............       09  MED                   MAJOR SKIN DISORDERS W CC..      1.0248         5.2         6.7
273.............       09  MED                   MAJOR SKIN DISORDERS W/O CC       .5638         3.4         4.2
274.............       09  MED                   MALIGNANT BREAST DISORDERS       1.1927         5.5         7.3
                                                  W CC.
275.............       09  MED                   MALIGNANT BREAST DISORDERS        .6647         3.1         4.6
                                                  W/O CC.
276.............       09  MED                   NON-MALIGANT BREAST               .7033         4.0         5.0
                                                  DISORDERS.
277.............       09  MED                   CELLULITIS AGE >17 W CC....       .8534         5.1         6.1
278.............       09  MED                   CELLULITIS AGE >17 W/O CC..       .5487         3.8         4.5
279.............       09  MED                   *CELLULITIS AGE 0-17.......       .6632         4.2         4.2
280.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT        .6941         3.5         4.4
                                                  TISS & BREAST AGE >17 W CC.
281.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT        .4593         2.5         3.1
                                                  TISS & BREAST AGE >17 W/O
                                                  CC.
282.............       09  MED                   *TRAUMA TO THE SKIN, SUBCUT       .2565         2.2         2.2
                                                  TISS & BREAST AGE 0-17.
283.............       09  MED                   MINOR SKIN DISORDERS W CC..       .7152         3.8         4.9
284.............       09  MED                   MINOR SKIN DISORDERS W/O CC       .4204         2.5         3.2
285.............       10  SURG                  AMPUTAT OF LOWER LIMB FOR        2.1297         9.1        11.4
                                                  ENDOCRINE,NUTRIT,& METABOL
                                                  DISORDERS.
286.............       10  SURG                  ADRENAL & PITUITARY              2.2343         5.3         6.9
                                                  PROCEDURES.
287.............       10  SURG                  SKIN GRAFTS & WOUND DEBRID       1.9569         8.9        11.7
                                                  FOR ENDOC, NUTRIT & METAB
                                                  DISORDERS.
288.............       10  SURG                  O.R. PROCEDURES FOR OBESITY      2.1590         4.9         6.0
289.............       10  SURG                  PARATHYROID PROCEDURES.....       .9573         1.9         3.0
290.............       10  SURG                  THYROID PROCEDURES.........       .8862         1.7         2.3
291.............       10  SURG                  THYROGLOSSAL PROCEDURES....       .5964         1.5         1.8
292.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        2.6892         8.8        11.6
                                                  METAB O.R. PROC W CC.
293.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        1.3059         4.3         5.9
                                                  METAB O.R. PROC W/O CC.
294.............       10  MED                   DIABETES AGE >35...........       .7608         3.8         4.9
295.............       10  MED                   DIABETES AGE 0-35..........       .7457         3.1         3.9
296.............       10  MED                   NUTRITIONAL & MISC                .8615         4.3         5.5
                                                  METABOLIC DISORDERS AGE
                                                  >17 W CC.
297.............       10  MED                   NUTRITIONAL & MISC                .5047         2.9         3.5
                                                  METABOLIC DISORDERS AGE
                                                  >17 W/O CC.
298.............       10  MED                   NUTRITIONAL & MISC                .4155         2.3         3.0
                                                  METABOLIC DISORDERS AGE 0-
                                                  17.
299.............       10  MED                   INBORN ERRORS OF METABOLISM       .9223         4.4         5.7
300.............       10  MED                   ENDOCRINE DISORDERS W CC...      1.1243         5.3         6.6
301.............       10  MED                   ENDOCRINE DISORDERS W/O CC.       .6078         3.0         3.8
302.............       11  SURG                  KIDNEY TRANSPLANT..........      3.3278         7.9         9.3
303.............       11  SURG                  KIDNEY,URETER & MAJOR            2.4884         7.5         9.0
                                                  BLADDER PROCEDURES FOR
                                                  NEOPLASM.
304.............       11  SURG                  KIDNEY,URETER & MAJOR            2.4618         7.4         9.7
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W CC.
305.............       11  SURG                  KIDNEY,URETER & MAJOR            1.1502         3.1         3.8
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W/O CC.
306.............       11  SURG                  PROSTATECTOMY W CC.........      1.2988         4.3         6.2
307.............       11  SURG                  PROSTATECTOMY W/O CC.......       .6050         1.9         2.2
308.............       11  SURG                  MINOR BLADDER PROCEDURES W       1.6896         4.8         6.9
                                                  CC.
309.............       11  SURG                  MINOR BLADDER PROCEDURES W/       .8936         1.8         2.3
                                                  O CC.
310.............       11  SURG                  TRANSURETHRAL PROCEDURES W       1.1366         3.3         4.7
                                                  CC.
311.............       11  SURG                  TRANSURETHRAL PROCEDURES W/       .5957         1.5         1.8
                                                  O CC.
312.............       11  SURG                  URETHRAL PROCEDURES, AGE         1.0782         3.3         4.8
                                                  >17 W CC.
313.............       11  SURG                  URETHRAL PROCEDURES, AGE          .6584         1.8         2.3
                                                  >17 W/O CC.

[[Page 40060]]

 
314.............       11  SURG                  *URETHRAL PROCEDURES, AGE 0-      .4944         2.3         2.3
                                                  17.
315.............       11  SURG                  OTHER KIDNEY & URINARY           2.1550         4.8         8.3
                                                  TRACT O.R. PROCEDURES.
316.............       11  MED                   RENAL FAILURE..............      1.3745         5.6         7.3
317.............       11  MED                   ADMIT FOR RENAL DIALYSIS...       .6130         2.0         2.9
318.............       11  MED                   KIDNEY & URINARY TRACT           1.1723         5.1         6.6
                                                  NEOPLASMS W CC.
319.............       11  MED                   KIDNEY & URINARY TRACT            .5852         2.1         2.8
                                                  NEOPLASMS W/O CC.
320.............       11  MED                   KIDNEY & URINARY TRACT            .8593         4.6         5.6
                                                  INFECTIONS AGE >17 W CC.
321.............       11  MED                   KIDNEY & URINARY TRACT            .5560         3.3         3.9
                                                  INFECTIONS AGE >17 W/O CC.
322.............       11  MED                   KIDNEY & URINARY TRACT            .5267         3.6         4.3
                                                  INFECTIONS AGE 0-17.
323.............       11  MED                   URINARY STONES W CC, &/OR         .7970         2.5         3.3
                                                  ESW LITHOTRIPSY.
324.............       11  MED                   URINARY STONES W/O CC......       .4422         1.6         1.9
325.............       11  MED                   KIDNEY & URINARY TRACT            .6336         3.1         4.0
                                                  SIGNS & SYMPTOMS AGE >17 W
                                                  CC.
326.............       11  MED                   KIDNEY & URINARY TRACT            .4120         2.1         2.7
                                                  SIGNS & SYMPTOMS AGE >17 W/
                                                  O CC.
327.............       11  MED                   KIDNEY & URINARY TRACT            .3697         2.8         3.2
                                                  SIGNS & SYMPTOMS AGE 0-17.
328.............       11  MED                   URETHRAL STRICTURE AGE >17        .7268         2.9         3.9
                                                  W CC.
329.............       11  MED                   URETHRAL STRICTURE AGE >17        .4458         1.6         2.0
                                                  W/O CC.
330.............       11  MED                   *URETHRAL STRICTURE AGE 0-        .3185         1.6         1.6
                                                  17.
331.............       11  MED                   OTHER KIDNEY & URINARY           1.0640         4.6         6.0
                                                  TRACT DIAGNOSES AGE >17 W
                                                  CC.
332.............       11  MED                   OTHER KIDNEY & URINARY            .6056         2.6         3.4
                                                  TRACT DIAGNOSES AGE >17 W/
                                                  O CC.
333.............       11  MED                   OTHER KIDNEY & URINARY            .7907         3.9         5.3
                                                  TRACT DIAGNOSES AGE 0-17.
334.............       12  SURG                  MAJOR MALE PELVIC                1.5177         4.3         5.0
                                                  PROCEDURES W CC.
335.............       12  SURG                  MAJOR MALE PELVIC                1.1047         3.1         3.3
                                                  PROCEDURES W/O CC.
336.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY       .8630         2.8         3.6
                                                  W CC.
337.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY       .5861         1.9         2.1
                                                  W/O CC.
338.............       12  SURG                  TESTES PROCEDURES, FOR           1.2191         3.7         5.6
                                                  MALIGNANCY.
339.............       12  SURG                  TESTES PROCEDURES, NON-          1.1555         3.3         5.0
                                                  MALIGNANCY AGE >17.
340.............       12  SURG                  *TESTES PROCEDURES, NON-          .2830         2.4         2.4
                                                  MALIGNANCY AGE 0-17.
341.............       12  SURG                  PENIS PROCEDURES...........      1.1306         2.0         3.0
342.............       12  SURG                  CIRCUMCISION AGE >17.......       .7852         2.5         3.3
343.............       12  SURG                  *CIRCUMCISION AGE 0-17.....       .1538         1.7         1.7
344.............       12  SURG                  OTHER MALE REPRODUCTIVE          1.1741         1.6         2.4
                                                  SYSTEM O.R. PROCEDURES FOR
                                                  MALIGNANCY.
345.............       12  SURG                  OTHER MALE REPRODUCTIVE           .9149         2.7         4.0
                                                  SYSTEM O.R. PROC EXCEPT
                                                  FOR MALIGNANCY.
346.............       12  MED                   MALIGNANCY, MALE                 1.0304         4.9         6.4
                                                  REPRODUCTIVE SYSTEM, W CC.
347.............       12  MED                   MALIGNANCY, MALE                  .5660         2.3         3.0
                                                  REPRODUCTIVE SYSTEM, W/O
                                                  CC.
348.............       12  MED                   BENIGN PROSTATIC                  .6998         3.4         4.4
                                                  HYPERTROPHY W CC.
349.............       12  MED                   BENIGN PROSTATIC                  .4128         2.0         2.5
                                                  HYPERTROPHY W/O CC.
350.............       12  MED                   INFLAMMATION OF THE MALE          .7164         3.8         4.6
                                                  REPRODUCTIVE SYSTEM.
351.............       12  MED                   *STERILIZATION, MALE.......       .2360         1.3         1.3
352.............       12  MED                   OTHER MALE REPRODUCTIVE           .6868         3.0         4.2
                                                  SYSTEM DIAGNOSES.
353.............       13  SURG                  PELVIC EVISCERATION,             1.8493         5.4         6.8
                                                  RADICAL HYSTERECTOMY &
                                                  RADICAL VULVECTOMY.
354.............       13  SURG                  UTERINE,ADNEXA PROC FOR NON-     1.5317         5.1         6.1
                                                  OVARIAN/ADNEXAL MALIG W CC.
355.............       13  SURG                  UTERINE,ADNEXA PROC FOR NON-      .9033         3.1         3.3
                                                  OVARIAN/ADNEXAL MALIG W/O
                                                  CC.
356.............       13  SURG                  FEMALE REPRODUCTIVE SYSTEM        .7440         2.0         2.3
                                                  RECONSTRUCTIVE PROCEDURES.
357.............       13  SURG                  UTERINE & ADNEXA PROC FOR        2.4380         7.5         9.2
                                                  OVARIAN OR ADNEXAL
                                                  MALIGNANCY.
358.............       13  SURG                  UTERINE & ADNEXA PROC FOR        1.1902         3.7         4.4
                                                  NON-MALIGNANCY W CC.
359.............       13  SURG                  UTERINE & ADNEXA PROC FOR         .8165         2.6         2.8
                                                  NON-MALIGNANCY W/O CC.
360.............       13  SURG                  VAGINA, CERVIX & VULVA            .8520         2.4         2.9
                                                  PROCEDURES.
361.............       13  SURG                  LAPAROSCOPY & INCISIONAL         1.0964         2.1         3.0
                                                  TUBAL INTERRUPTION.
362.............       13  SURG                  *ENDOSCOPIC TUBAL                 .3017         1.4         1.4
                                                  INTERRUPTION.
363.............       13  SURG                  D&C, CONIZATION & RADIO-          .8158         2.6         3.6
                                                  IMPLANT, FOR MALIGNANCY.
364.............       13  SURG                  D&C, CONIZATION EXCEPT FOR        .8170         2.9         4.1
                                                  MALIGNANCY.
365.............       13  SURG                  OTHER FEMALE REPRODUCTIVE        2.0008         5.8         8.1
                                                  SYSTEM O.R. PROCEDURES.
366.............       13  MED                   MALIGNANCY, FEMALE               1.2699         5.6         7.4
                                                  REPRODUCTIVE SYSTEM W CC.
367.............       13  MED                   MALIGNANCY, FEMALE                .5767         2.4         3.2
                                                  REPRODUCTIVE SYSTEM W/O CC.
368.............       13  MED                   INFECTIONS, FEMALE               1.1355         5.6         7.0
                                                  REPRODUCTIVE SYSTEM.
369.............       13  MED                   MENSTRUAL & OTHER FEMALE          .5581         2.5         3.4
                                                  REPRODUCTIVE SYSTEM
                                                  DISORDERS.
370.............       14  SURG                  CESAREAN SECTION W CC......      1.0572         4.7         6.1
371.............       14  SURG                  CESAREAN SECTION W/O CC....       .6845         3.3         3.7

[[Page 40061]]

 
372.............       14  MED                   VAGINAL DELIVERY W                .5550         2.7         3.3
                                                  COMPLICATING DIAGNOSES.
373.............       14  MED                   VAGINAL DELIVERY W/O              .3774         2.0         2.3
                                                  COMPLICATING DIAGNOSES.
374.............       14  SURG                  VAGINAL DELIVERY W                .6835         2.5         3.1
                                                  STERILIZATION &/OR D&C.
375.............       14  SURG                  VAGINAL DELIVERY W O.R.           .5759         2.1         2.3
                                                  PROC EXCEPT STERIL &/OR
                                                  D&C.
376.............       14  MED                   POSTPARTUM & POST ABORTION        .4963         2.5         3.2
                                                  DIAGNOSES W/O O.R.
                                                  PROCEDURE.
377.............       14  SURG                  POSTPARTUM & POST ABORTION       1.6892         3.8         5.6
                                                  DIAGNOSES W O.R. PROCEDURE.
378.............       14  MED                   ECTOPIC PREGNANCY..........       .8017         2.0         2.4
379.............       14  MED                   THREATENED ABORTION........       .4521         2.4         3.6
380.............       14  MED                   ABORTION W/O D&C...........       .4201         1.6         2.1
381.............       14  SURG                  ABORTION W D&C, ASPIRATION        .6628         1.8         2.5
                                                  CURETTAGE OR HYSTEROTOMY.
382.............       14  MED                   FALSE LABOR................       .1599         1.2         1.3
383.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES        .4915         2.8         3.8
                                                  W MEDICAL COMPLICATIONS.
384.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES        .3626         1.6         2.1
                                                  W/O MEDICAL COMPLICATIONS.
385.............       15  MED                   *NEONATES, DIED OR               1.3743         1.8         1.8
                                                  TRANSFERRED TO ANOTHER
                                                  ACUTE CARE FACILITY.
386.............       15  MED                   *EXTREME IMMATURITY OR           4.5319        17.9        17.9
                                                  RESPIRATORY DISTRESS
                                                  SYNDROME, NEONATE.
387.............       15  MED                   *PREMATURITY W MAJOR             3.0952        13.3        13.3
                                                  PROBLEMS.
388.............       15  MED                   *PREMATURITY W/O MAJOR           1.8676         8.6         8.6
                                                  PROBLEMS.
389.............       15  MED                   FULL TERM NEONATE W MAJOR        3.1794         9.3        16.0
                                                  PROBLEMS.
390.............       15  MED                   NEONATE W OTHER SIGNIFICANT      1.1253         3.5         4.3
                                                  PROBLEMS.
391.............       15  MED                   *NORMAL NEWBORN............       .1524         3.1         3.1
392.............       16  SURG                  SPLENECTOMY AGE >17........      3.3892         8.3        10.8
393.............       16  SURG                  *SPLENECTOMY AGE 0-17......      1.3462         9.1         9.1
394.............       16  SURG                  OTHER O.R. PROCEDURES OF         1.8231         5.1         8.1
                                                  THE BLOOD AND BLOOD
                                                  FORMING ORGANS.
395.............       16  MED                   RED BLOOD CELL DISORDERS          .8192         3.5         4.7
                                                  AGE >17.
396.............       16  MED                   RED BLOOD CELL DISORDERS         1.0407         3.9         5.0
                                                  AGE 0-17.
397.............       16  MED                   COAGULATION DISORDERS......      1.2671         4.2         5.6
398.............       16  MED                   RETICULOENDOTHELIAL &            1.3082         5.1         6.4
                                                  IMMUNITY DISORDERS W CC.
399.............       16  MED                   RETICULOENDOTHELIAL &             .6675         3.0         3.7
                                                  IMMUNITY DISORDERS W/O CC.
400.............       17  SURG                  LYMPHOMA & LEUKEMIA W MAJOR      2.9346         7.4        10.5
                                                  O.R. PROCEDURE.
401.............       17  SURG                  LYMPHOMA & NON-ACUTE             2.9905         9.9        12.8
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W CC.
402.............       17  SURG                  LYMPHOMA & NON-ACUTE             1.1594         3.1         4.4
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W/O CC.
403.............       17  MED                   LYMPHOMA & NON-ACUTE             1.8579         6.8         9.1
                                                  LEUKEMIA W CC.
404.............       17  MED                   LYMPHOMA & NON-ACUTE              .8718         3.4         4.6
                                                  LEUKEMIA W/O CC.
405.............       17  MED                   *ACUTE LEUKEMIA W/O MAJOR        1.9086         4.9         4.9
                                                  O.R. PROCEDURE AGE 0-17.
406.............       17  SURG                  MYELOPROLIF DISORD OR            2.9939         8.4        11.1
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W CC.
407.............       17  SURG                  MYELOPROLIF DISORD OR            1.2426         3.8         4.7
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W/O CC.
408.............       17  SURG                  MYELOPROLIF DISORD OR            2.2144         6.0         9.2
                                                  POORLY DIFF NEOPL W OTHER
                                                  O.R.PROC.
409.............       17  MED                   RADIOTHERAPY...............      1.1575         4.9         6.3
410.............       17  MED                   CHEMOTHERAPY W/O ACUTE            .9991         3.3         4.1
                                                  LEUKEMIA AS SECONDARY
                                                  DIAGNOSIS.
411.............       17  MED                   HISTORY OF MALIGNANCY W/O         .4481         1.8         2.3
                                                  ENDOSCOPY.
412.............       17  MED                   HISTORY OF MALIGNANCY W           .5958         1.9         2.4
                                                  ENDOSCOPY.
413.............       17  MED                   OTHER MYELOPROLIF DIS OR         1.3894         6.1         7.8
                                                  POORLY DIFF NEOPL DIAG W
                                                  CC.
414.............       17  MED                   OTHER MYELOPROLIF DIS OR          .7418         3.5         4.6
                                                  POORLY DIFF NEOPL DIAG W/O
                                                  CC.
415.............       18  SURG                  O.R. PROCEDURE FOR               3.9067        12.6        16.3
                                                  INFECTIOUS & PARASITIC
                                                  DISEASES.
416.............       18  MED                   SEPTICEMIA AGE >17.........      1.6226         6.4         8.1
417.............       18  MED                   SEPTICEMIA AGE 0-17........       .8915         4.4         5.4
418.............       18  MED                   POSTOPERATIVE & POST-            1.0493         5.3         6.6
                                                  TRAUMATIC INFECTIONS.
419.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE       .8618         4.0         5.0
                                                  >17 W CC.
420.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE       .6112         3.0         3.6
                                                  >17 W/O CC.
421.............       18  MED                   VIRAL ILLNESS AGE >17......       .6640         3.2         3.9
422.............       18  MED                   VIRAL ILLNESS & FEVER OF          .4757         2.6         3.1
                                                  UNKNOWN ORIGIN AGE 0-17.
423.............       18  MED                   OTHER INFECTIOUS &               1.8365         6.7         9.0
                                                  PARASITIC DISEASES
                                                  DIAGNOSES.
424.............       19  SURG                  O.R. PROCEDURE W PRINCIPAL       2.4518        10.9        15.9
                                                  DIAGNOSES OF MENTAL
                                                  ILLNESS.
425.............       19  MED                   ACUTE ADJUSTMENT REACTION &       .6789         3.2         4.2
                                                  PSYCHOSOCIAL DYSFUNCTION.

[[Page 40062]]

 
426.............       19  MED                   DEPRESSIVE NEUROSES........       .5261         3.5         4.7
427.............       19  MED                   NEUROSES EXCEPT DEPRESSIVE.       .5348         3.5         5.0
428.............       19  MED                   DISORDERS OF PERSONALITY &        .7242         5.0         7.8
                                                  IMPULSE CONTROL.
429.............       19  MED                   ORGANIC DISTURBANCES &            .8367         5.2         6.9
                                                  MENTAL RETARDATION.
430.............       19  MED                   PSYCHOSES..................       .7676         6.7         8.9
431.............       19  MED                   CHILDHOOD MENTAL DISORDERS.       .6416         5.1         7.1
432.............       19  MED                   OTHER MENTAL DISORDER             .7100         3.4         5.1
                                                  DIAGNOSES.
433.............       20  MED                   ALCOHOL/DRUG ABUSE OR             .2888         2.3         3.2
                                                  DEPENDENCE, LEFT AMA.
434.............       20  MED                   NO LONGER VALID............       .0000          .0          .0
435.............       20  MED                   NO LONGER VALID............       .0000          .0          .0
436.............       20  MED                   NO LONGER VALID............       .0000          .0          .0
437.............       20  MED                   NO LONGER VALID............       .0000          .0          .0
438.............       20  ....................  NO LONGER VALID............       .0000          .0          .0
439.............       21  SURG                  SKIN GRAFTS FOR INJURIES...      1.9332         6.7         9.5
440.............       21  SURG                  WOUND DEBRIDEMENTS FOR           2.0806         7.2        10.3
                                                  INJURIES.
441.............       21  SURG                  HAND PROCEDURES FOR               .9295         2.3         3.3
                                                  INJURIES.
442.............       21  SURG                  OTHER O.R. PROCEDURES FOR        2.5304         6.8         9.6
                                                  INJURIES W CC.
443.............       21  SURG                  OTHER O.R. PROCEDURES FOR         .9920         2.7         3.6
                                                  INJURIES W/O CC.
444.............       21  MED                   TRAUMATIC INJURY AGE >17 W        .7277         3.4         4.4
                                                  CC.
445.............       21  MED                   TRAUMATIC INJURY AGE >17 W/       .4716         2.4         3.0
                                                  O CC.
446.............       21  MED                   *TRAUMATIC INJURY AGE 0-17.       .2959         2.4         2.4
447.............       21  MED                   ALLERGIC REACTIONS AGE >17.       .4825         1.8         2.5
448.............       21  MED                   *ALLERGIC REACTIONS AGE 0-        .0973         2.9         2.9
                                                  17.
449.............       21  MED                   POISONING & TOXIC EFFECTS         .8309         2.8         4.0
                                                  OF DRUGS AGE >17 W CC.
450.............       21  MED                   POISONING & TOXIC EFFECTS         .4139         1.6         2.0
                                                  OF DRUGS AGE >17 W/O CC.
451.............       21  MED                   *POISONING & TOXIC EFFECTS        .2627         2.1         2.1
                                                  OF DRUGS AGE 0-17.
452.............       21  MED                   COMPLICATIONS OF TREATMENT       1.0122         3.8         5.2
                                                  W CC.
453.............       21  MED                   COMPLICATIONS OF TREATMENT        .4980         2.2         2.8
                                                  W/O CC.
454.............       21  MED                   OTHER INJURY, POISONING &         .8692         3.4         4.9
                                                  TOXIC EFFECT DIAG W CC.
455.............       21  MED                   OTHER INJURY, POISONING &         .4630         1.9         2.6
                                                  TOXIC EFFECT DIAG W/O CC.
456.............       22  ....................  NO LONGER VALID............       .0000          .0          .0
457.............       22  MED                   NO LONGER VALID............       .0000          .0          .0
458.............       22  SURG                  NO LONGER VALID............       .0000          .0          .0
459.............       22  SURG                  NO LONGER VALID............       .0000          .0          .0
460.............       22  MED                   NO LONGER VALID............       .0000          .0          .0
461.............       23  SURG                  O.R. PROC W DIAGNOSES OF         1.1963         2.5         4.6
                                                  OTHER CONTACT W HEALTH
                                                  SERVICES.
462.............       23  MED                   REHABILITATION.............      1.2125        10.4        12.3
463.............       23  MED                   SIGNS & SYMPTOMS W CC......       .6800         3.4         4.3
464.............       23  MED                   SIGNS & SYMPTOMS W/O CC....       .4628         2.5         3.1
465.............       23  MED                   AFTERCARE W HISTORY OF            .5445         2.1         3.1
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.
466.............       23  MED                   AFTERCARE W/O HISTORY OF          .6416         2.3         3.8
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.
467.............       23  MED                   OTHER FACTORS INFLUENCING         .4585         2.1         3.1
                                                  HEALTH STATUS.
468.............           ....................  EXTENSIVE O.R. PROCEDURE         3.8756        11.4        14.7
                                                  UNRELATED TO PRINCIPAL
                                                  DIAGNOSIS.
469.............           ....................  **PRINCIPAL DIAGNOSIS             .0000          .0          .0
                                                  INVALID AS DISCHARGE
                                                  DIAGNOSIS.
470.............           ....................  **UNGROUPABLE..............       .0000          .0          .0
471.............       08  SURG                  BILATERAL OR MULTIPLE MAJOR      3.0067         5.0         5.7
                                                  JOINT PROCS OF LOWER
                                                  EXTREMITY.
472.............       22  SURG                  NO LONGER VALID............       .0000          .0          .0
473.............       17  SURG                  ACUTE LEUKEMIA W/O MAJOR         3.9324         9.8        15.1
                                                  O.R. PROCEDURE AGE >17.
474.............       04  SURG                  NO LONGER VALID............       .0000          .0          .0
475.............       04  MED                   RESPIRATORY SYSTEM               3.9253        10.0        12.7
                                                  DIAGNOSIS WITH VENTILATOR
                                                  SUPPORT.
476.............           SURG                  PROSTATIC O.R. PROCEDURE         2.2915        10.0        12.3
                                                  UNRELATED TO PRINCIPAL
                                                  DIAGNOSIS.
477.............           SURG                  NON-EXTENSIVE O.R.               1.9568         6.7         9.3
                                                  PROCEDURE UNRELATED TO
                                                  PRINCIPAL DIAGNOSIS.
478.............       05  SURG                  OTHER VASCULAR PROCEDURES W      2.4161         5.9         8.2
                                                  CC.
479.............       05  SURG                  OTHER VASCULAR PROCEDURES W/     1.3900         2.8         3.6
                                                  O CC.
480.............      PRE  SURG                  LIVER TRANSPLANT...........     10.9812        18.1        23.9
481.............      PRE  SURG                  BONE MARROW TRANSPLANT.....      8.0438        23.6        25.8
482.............      PRE  SURG                  TRACHEOSTOMY FOR FACE,MOUTH      3.8583        11.4        14.3
                                                  & NECK DIAGNOSES.
483.............      PRE  SURG                  TRACHEOSTOMY EXCEPT FOR         15.4629        34.2        41.5
                                                  FACE,MOUTH & NECK
                                                  DIAGNOSES.
484.............       24  SURG                  CRANIOTOMY FOR MULTIPLE          5.2963        11.7        14.9
                                                  SIGNIFICANT TRAUMA.

[[Page 40063]]

 
485.............       24  SURG                  LIMB REATTACHMENT, HIP AND       3.1724         8.5        10.5
                                                  FEMUR PROC FOR MULTIPLE
                                                  SIGNIFICANT TRA.
486.............       24  SURG                  OTHER O.R. PROCEDURES FOR        5.2888        11.0        14.3
                                                  MULTIPLE SIGNIFICANT
                                                  TRAUMA.
487.............       24  MED                   OTHER MULTIPLE SIGNIFICANT       1.9585         6.3         8.2
                                                  TRAUMA.
488.............       25  SURG                  HIV W EXTENSIVE O.R.             5.1965        14.9        19.7
                                                  PROCEDURE.
489.............       25  MED                   HIV W MAJOR RELATED              1.8948         7.0         9.4
                                                  CONDITION.
490.............       25  MED                   HIV W OR W/O OTHER RELATED       1.0584         4.3         5.8
                                                  CONDITION.
491.............       08  SURG                  MAJOR JOINT & LIMB               1.6353         3.0         3.5
                                                  REATTACHMENT PROCEDURES OF
                                                  UPPER EXTREMITY.
492.............       17  MED                   CHEMOTHERAPY W ACUTE             4.8886        13.6        19.0
                                                  LEUKEMIA AS SECONDARY
                                                  DIAGNOSIS.
493.............       07  SURG                  LAPAROSCOPIC                     1.8411         4.9         6.3
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W CC.
494.............       07  SURG                  LAPAROSCOPIC                      .9754         1.9         2.4
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W/O CC.
495.............      PRE  SURG                  LUNG TRANSPLANT............      8.8252        13.8        16.2
496.............       08  SURG                  COMBINED ANTERIOR/POSTERIOR      5.7281         8.6        10.5
                                                  SPINAL FUSION.
497.............       08  SURG                  SPINAL FUSION EXCEPT             3.2324         5.8         6.9
                                                  CERVICAL W CC.
498.............       08  SURG                  SPINAL FUSION EXCEPT             2.3026         3.9         4.3
                                                  CERVICAL W/O CC.
499.............       08  SURG                  BACK & NECK PROCEDURES           1.4507         3.8         5.0
                                                  EXCEPT SPINAL FUSION W CC.
500.............       08  SURG                  BACK & NECK PROCEDURES            .9385         2.2         2.6
                                                  EXCEPT SPINAL FUSION W/O
                                                  CC.
501.............       08  SURG                  KNEE PROCEDURES W PDX OF         2.7485         9.8        11.9
                                                  INFECTION W CC.
502.............       08  SURG                  KNEE PROCEDURES W PDX OF         1.5544         5.9         6.9
                                                  INFECTION W/O CC.
503.............       08  SURG                  KNEE PROCEDURES W/O PDX OF       1.2291         3.3         4.2
                                                  INFECTION.
504.............       22  SURG                  EXTENSIVE 3RD DEGREE BURNS      14.1729        28.8        34.7
                                                  W SKIN GRAFT.
505.............       22  MED                   EXTENSIVE 3RD DEGREE BURNS       1.4994         2.0         3.4
                                                  W/O SKIN GRAFT.
506.............       22  SURG                  FULL THICKNESS BURN W SKIN       4.9233        15.7        19.9
                                                  GRAFT OR INHAL INJ W CC OR
                                                  SIG TRAUMA.
507.............       22  SURG                  FULL THICKNESS BURN W SKIN       1.8583         7.3         9.3
                                                  GRFT OR INHAL INJ W/O CC
                                                  OR SIG TRAUMA.
508.............       22  MED                   FULL THICKNESS BURN W/O          1.2967         6.1         8.3
                                                  SKIN GRFT OR INHAL INJ W
                                                  CC OR SIG TRAUMA.
509.............       22  MED                   FULL THICKNESS BURN W/O           .7265         3.7         4.9
                                                  SKIN GRFT OR INH INJ W/O
                                                  CC OR SIG TRAUMA.
510.............       22  MED                   NON-EXTENSIVE BURNS W CC OR      1.3681         5.8         8.0
                                                  SIGNIFICANT TRAUMA.
511.............       22  MED                   NON-EXTENSIVE BURNS W/O CC        .7656         3.6         5.2
                                                  OR SIGNIFICANT TRAUMA.
512.............      PRE  SURG                  SIMULTANEOUS PANCREAS/           5.7813        12.7        14.9
                                                  KIDNEY TRANSPLANT.
513.............      PRE  SURG                  PANCREAS TRANSPLANT........      5.8400         9.7        11.1
514.............       05  SURG                  CARDIAC DEFIBRILLATOR            6.3663         6.7         8.8
                                                  IMPLANT W CARDIAC CATH.
515.............       05  SURG                  CARDIAC DEFIBRILLATOR            4.9905         4.2         6.7
                                                  IMPLANT W/O CARDIAC CATH.
516.............       05  SURG                  PERCUTANEOUS CARDIOVASC          2.7475         4.1         5.0
                                                  PROC W AMI.
517.............       05  SURG                  PERC CARDIO PROC W CORONARY      2.1379         1.9         2.7
                                                  ARTERY STENT W/O AMI.
518.............       05  SURG                  PERC CARDIO PROC W/O             1.6989         2.5         3.7
                                                  CORONARY ARTERY STENT OR
                                                  AMI.
519.............       08  SURG                  CERVICAL SPINAL FUSION W CC      2.3249         3.8         5.6
520.............       08  SURG                  CERVICAL SPINAL FUSION W/O       1.4195         1.7         2.2
                                                  CC.
521.............       20  MED                   ALCOHOL/DRUG ABUSE OR             .7355         5.0         6.4
                                                  DEPENDENCE W CC.
522.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W        .6249         8.6        10.4
                                                  REHABILITATION THERAPY W/O
                                                  CC.
523.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W/       .3997         3.5         4.3
                                                  O REHABILITATION THERAPY W/
                                                  O CC.
----------------------------------------------------------------------------------------------------------------
*Medicare data have been supplemented by data from 19 states for low volume DRGs.
**DRGs 469 and 470 contain cases which could not be assigned to valid DRGs.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is presented for informational purposes only.
Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients.

      
  

  

  

  

  

  Federal Register / Vol. 66, No. 148 / Wednesday, August 1, 2001 / 
Rules and Regulations  

[[Page 40063]]


      

                                         Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
 Diagnosis
    Code              Description                    CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
     256.31  Premature menopause..........  N                             13  358, 359, 369
     256.39  Other ovarian failure........  N                             13  358, 359, 369
      277.7  Dysmetabolic Syndrome X......  N                             10  299
     464.00  Acute laryngitis, without      N                              3  68, 69, 70
              mention of obstruction.                                    pre  482
     464.01  Acute laryngitis, with         N                              3  68, 69, 70
              obstruction.                                               pre  482

[[Page 40064]]

 
     464.50  Unspecified supraglottis,      N                              3  68, 69, 70
              without mention of                                         pre  482
              obstruction.
     464.51  Unspecified supraglottis,      N                              3  68, 69, 70
              with obstruction.                                          pre  482
     521.00  Unspecified dental caries....  N                              3  185, 186, 187
                                                                         pre  482
     521.01  Dental caries limited to       N                              3  185, 186, 187
              enamel.                                                    pre  482
     521.02  Dental caries extending into   N                              3  185, 186, 187
              dentine.                                                   pre  482
     521.03  Dental caries extending into   N                              3  185, 186, 187
              pulp.                                                      pre  482
     521.04  Arrested dental caries.......  N                              3  185, 186, 187
                                                                         pre  482
     521.05  Odontoclasia.................  N                              3  185, 186, 187
                                                                         pre  482
     521.09  Other dental caries..........  N                              3  185, 186, 187
                                                                         pre  482
     525.10  Unspecified acquired absence   N                              3  185, 186, 187
              of teeth.                                                  pre  482
     525.11  Loss of teeth due to trauma..  N                              3  185, 186, 187
                                                                         pre  482
     525.12  Loss of teeth due to           N                              3  185, 186, 187
              periodontal disease.                                       pre  482
     525.13  Loss of teeth due to caries..  N                              3  185, 186, 187
                                                                         pre  482
     525.19  Other loss of teeth..........  N                              3  185, 186, 187
                                                                         pre  482
     530.12  Acute esophagitis............  N                              6  182, 183, 184
     564.00  Unspecified constipation.....  N                              6  182, 183, 184
     564.01  Slow transit constipation....  N                              6  182, 183, 184
     564.02  Outlet dysfunction             N                              6  182, 183, 184
              constipation.
     564.09  Other constipation...........  N                              6  182, 183, 184
      602.3  Dysplasia of prostate........  N                             12  352
     608.82  Hematospermia................  N                             12  352
     608.87  Retrograde ejaculation.......  N                             12  352
     692.76  Sunburn of second degree.....  N                              9  283, 284
     692.77  Sunburn of third degree......  N                              9  283, 284
     718.70  Developmental dislocation of   N                              8  256
              joint, site unspecified.
     718.71  Developmental dislocation of   N                              8  256
              joint, shoulder region.
     718.72  Developmental dislocation of   N                              8  256
              joint, upper arm.
     718.73  Developmental dislocation of   N                              8  256
              joint, forearm.
     718.74  Developmental dislocation of   N                              8  256
              joint, hand.
     718.75  Developmental dislocation of   N                              8  256
              joint, pelvic region and
              thigh.
     718.76  Developmental dislocation of   N                              8  256
              joint, lower leg.
     718.77  Developmental dislocation of   N                              8  256
              joint, ankle and foot.
     718.78  Developmental dislocation of   N                              8  256
              joint, other specified sites.
     718.79  Developmental dislocation of   N                              8  256
              joint, multiple sites.
     733.93  Stress fracture of tibia or    Y                              8  239
              fibula.
     733.94  Stress fracture of the         Y                              8  239
              metatarsals.
     733.95  Stress fracture of other bone  Y                              8  239
     772.10  Intraventricular hemorrhage,   Y                             15  387, 389
              unspecified grade.
     772.11  Intraventricular hemorrhage,   Y                             15  387, 389
              Grade I.
     772.12  Intraventricular hemorrhage,   Y                             15  387, 389
              Grade II.
     772.13  Intraventricular hemorrhage,   Y                             15  387, 389
              Grade III.
     772.14  Intraventricular hemorrhage,   Y                             15  387, 389
              Grade IV.
      779.7  Perventricular leukomalacia..  Y                             15  387, 389
     793.80  Unspecified abnormal           N                              9  276
              mammogram.
     793.81  Mammographic                   N                              9  276
              microcalcification.
     793.89  Other abnormal findings on     N                              9  276
              radiological examination
              breast.
      840.7  Superior glenoid labrum        N                              8  253, 254, 255
              lesions (SLAP).                                             24  487
     997.71  Vascular complications of      Y                              6  188, 189, 190
              mesenteric artery.                                          15  387, 389
     997.72  Vascular complications of      Y                             11  331, 332, 333
              renal artery.                                               15  387, 389
     997.79  Vascular complications of      Y                              5  130, 131
              other vessels.                                              15  387, 389
     V10.53  Personal history of malignant  N                             17  411, 412
              neoplasm, renal pelvis.
     V45.84  Dental restoration status....  N                             23  467
     V49.82  Dental sealant status........  N                             23  467

[[Page 40065]]

 
     V83.01  Asymptomatic hemophilia A      N                             23  467
              carrier.
     V83.02  Symptomatic hemophilia A       N                             23  467
              carrier.
----------------------------------------------------------------------------------------------------------------


                                         Table 6B.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
 Procedure
    Code              Description                    OR               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
      37.28  Intracardiac echocardiography  N
      44.32  Percutaneous [endoscopic]      Y                              6  154-156
              gastrojejunostomy.                                           7  201
                                                                          10  288
                                                                          17  400, 406, 407
      67.51  Transabdominal cerclage of     Y                             13  360
              cervix.                                                     14  372, 373
                                                                          21  442, 443
                                                                          24  486
      67.59  Other repair of internal       Y                             13  360
              cervical os.                                                14  372, 373
                                                                          21  442, 443
                                                                          24  486
      75.38  Fetal pulse oximetry.........  N
      81.30  Refusion of spine, not         Y                              1  4
              otherwise specified.                                         8  497, 498
                                                                          21  442, 443
                                                                          24  486
      81.31  Refusion of Atlas-axis spine.  Y                              1  4
                                                                           8  497, 498
                                                                          21  442, 443
                                                                          24  486
      81.32  Refusion of other cervical     Y                              1  4
              spine, anterior technique.                                   8  496, 519, 520
                                                                          21  442, 443
                                                                          24  486
      81.33  Refusion of other cervical     Y                              1  4
              spine, posterior technique.                                  8  496, 519, 520
                                                                          21  442, 443
                                                                          24  486
      81.34  Refusion of dorsal and         Y                              1  4
              dorsolumbar spine, anterior                                  8  496, 497, 498
              technique.                                                  21  442, 443
                                                                          24  486
      81.35  Refusion of dorsal and         Y                              1  4
              dorsolumbar spine, posterior                                 8  496, 497, 498
              technique.                                                  21  442, 443
                                                                          24  486
      81.36  Refusion of lumbar and         Y                              1  4
              lumbosacral spine, anterior                                  8  496, 497, 498
              technique.                                                  21  442, 443
                                                                          24  486
      81.37  Refusion of lumbar and         Y                              1  4
              lumbosacral spine, lateral                                   8  496, 497, 498
              transverse process technique.                               21  442, 443
                                                                          24  486
      81.38  Refusion of lumbar and         Y                              1  4
              lumbosacral spine, posterior                                 8  496, 497, 498
              technique.                                                  21  442, 443
                                                                          24  486
      81.39  Refusion of spine, not         Y                              1  4
              elsewhere classified.                                        8  497, 498
                                                                          21  442, 443
                                                                          24  486
      97.44  Nonoperative removal of heart  N
              assist system.
----------------------------------------------------------------------------------------------------------------


[[Page 40066]]


                                       Table 6C.--Invalid Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
 Diagnosis
    Code              Description                    CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
      256.3  Other ovarian failure........  N                             13  358, 359, 369
      464.0  Acute laryngitis.............  N                              3  68, 69, 70
                                                                         pre  482
      521.0  Dental caries................  N                              3  185, 186, 187
                                                                         pre  482
      525.1  Loss of teeth due to           N                              3  185, 186, 187
              accident, extraction, or                                   pre  482
              local periodontal disease.
      564.0  Constipation.................  N                              6  182, 183, 184
      772.1  Intraventricular hemorrhage..  Y                             15  387, 389
      793.8  Nonspecific abnormal findings  N                              9  276
              on radiological and other
              examinations of body
              structure, breast.
----------------------------------------------------------------------------------------------------------------


                                       Table 6D.--Invalid Procedure Codes
----------------------------------------------------------------------------------------------------------------
 Procedure
    Code              Description                    OR               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
       67.5  Repair of internal cervical    Y                             13  360
              os.                                                         14  372, 373
                                                                          21  442, 443
                                                                          24  486
      81.09  Refusion of spine, any level   Y                              1  4
              or technique.                                                8  497, 498
                                                                          21  442, 443
                                                                          24  486
----------------------------------------------------------------------------------------------------------------


                                    Table 6E.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
 Diagnosis
    Code              Description                    CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
     411.81  Acute coronary occlusion       Y                              5  124, 140
              without myocardial
              infarction.
     493.00  Extrinsic asthma without       N                              4  96, 97, 98
              mention of status
              asthmaticus or acute
              exacerbation or unspecified.
     493.10  Intrinsic asthma without       N                              4  96, 97, 98
              mention of status
              asthmaticus or acute
              exacerbation or unspecified.
     493.20  Chronic obstructive asthma     Y                              4  88
              without mention of status
              asthmaticus or acute
              exacerbation or unspecified.
     493.90  Asthma, unspecified without    N                              4  96, 97, 98
              mention of status
              asthmaticus or acute
              exacerbation or unspecified.
      V70.7  Examination of participant in  N                             23  467
              clinical trial.
----------------------------------------------------------------------------------------------------------------


                                    Table 6F.--Revised Procedure Code Titles
----------------------------------------------------------------------------------------------------------------
 Procedure
    Code              Description                    OR               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
      75.34  Other fetal monitoring.......  N
----------------------------------------------------------------------------------------------------------------


[[Page 40067]]


             Table 6G.--Additions to the CC Exclusions List
   CCs that are added to the list are in Table 6F-Additions to the CC
    Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
 indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
 
------------------------------------------------------------------------
*25631      80600     82010    80637    80606    82021    77212    77210
  2580      80601     82011    80638    80607    82022    77213    77211
  2581      80602     82012    80639    80608    82030    77214    77212
  2588      80603     82013    8064     80609    82031    7797     77213
  2589      80604     82019    8065     80610    82032  *7729      77214
*25639      80605     82020    80660    80611    8208     77210    7797
  2580      80606     82021    80661    80612    8209     77211  *7769
  2581      80607     82022    80662    80613    82100    77212    77210
  2588      80608     82030    80669    80614    82101    77213    77211
  2589      80609     82031    80670    80615    82110    77214    77212
*6023       80610     82032    80671    80616    82111    7797     77213
  5960      80611     8208     80672    80617  *7720    *7760      77214
  5996      80612     8209     80679    80618    77210    77210    7797
  6010      80613     82100    8068     80619    77211    77211  *7797
  6012      80614     82101    8069     80620    77212    77212    7722
  6013      80615     82110    8080     80621    77213    77213    7797
  6021      80616     82111    8082     80622    77214    77214  *7798
  78820     80617   *73394     8083     80623    7797     7797     77210
  78829     80618     73310    80843    80624  *77210   *7761      77211
*60887      80619     73311    80849    80625    77210    77210    77212
  5970      80620     73312    80851    80626    77211    77211    77213
  5994      80621     73313    80852    80627    77212    77212    77214
*73310      80622     73314    80853    80628    77213    77213    7797
  73393     80623     73315    80859    80629    77214    77214  *9972
  73394     80624     73316    8088     80630    7722     7797     99771
  73395     80625     73319    8089     80631    7797   *7762      99772
*73311      80626     73393    82000    80632  *77211     77210    99779
  73393     80627     73394    82001    80633    77210    77211  *99771
  73394     80628     73395    82002    80634    77211    77212    53640
  73395     80629     8058     82003    80635    77212    77213    53641
*73312      80630     8059     82009    80636    77213    77214    53642
  73393     80631     80600    82010    80637    77214    7797     53649
  73394     80632     80601    82011    80638    7722   *7763      56962
  73395     80633     80602    82012    80639    7797     77210    9974
*73313      80634     80603    82013    8064   *77212     77211    99771
  73393     80635     80604    82019    8065     77210    77212    99772
  73394     80636     80605    82020    80660    77211    77213    99779
  73395     80637     80606    82021    80661    77212    77214  *99772
*73314      80638     80607    82022    80662    77213    7797     9975
  73393     80639     80608    82030    80669    77214  *7764      99771
  73394     8064      80609    82031    80670    7722     77210    99772
  73395     8065      80610    82032    80671    7797     77211    99779
*73315      80660     80611    8208     80672  *77213     77212  *99779
  73393     80661     80612    8209     80679    77210    77213    9972
  73394     80662     80613    82100    8068     77211    77214    99771
  73395     80669     80614    82101    8069     77212    7797     99772
*73316      80670     80615    82110    8080     77213  *7765      99779
  73393     80671     80616    82111    8082     77214    77210  *99791
  73394     80672     80617  *73395     8083     7722     77211    99771
  73395     80679     80618    73310    80843    7797     77212    99772
*73319      8068      80619    73311    80849  *77214     77213    99779
  73393     8069      80620    73312    80851    77210    77214  *99799
  73394     8080      80621    73313    80852    77211    7797     99771
  73395     8082      80622    73314    80853    77212  *7766      99772
*73393      8083      80623    73315    80859    77213    77210    99779
  73310     80843     80624    73316    8088     77214    77211  *99881
  73311     80849     80625    73319    8089     7722     77212    99771
  73312     80851     80626    73393    82000    7797     77213    99772
  73313     80852     80627    73394    82001  *7722      77214    99779
  73314     80853     80628    73395    82002    77210    7797   *99883
  73315     80859     80629    8058     82003    77211  *7767      99771
  73316     8088      80630    8059     82009    77212    77210    99772
  73319     8089      80631    80600    82010    77213    77211    99779
  73393     82000     80632    80601    82011    77214    77212  *99889
  73394     82001     80633    80602    82012    7797     77213    99771
  73395     82002     80634    80603    82013  *7728      77214    99772
  8058      82003     80635    80604    82019    77210    7797     99779
  8059      82009     80636    80605    82020    77211  *7768    *9989
  99771
  99772
  99779
------------------------------------------------------------------------


[[Page 40068]]


             Table 6H.--Deletions to the CC Exclusions List
 CCs that are deleted from the list are in Table 6G-Deletions to the CC
    Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
 indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
 
------------------------------------------------------------------------
*2563
  2580
  2581
  2588
  2589
*7720
  7721
*7721
  7721
  7722
*7722
  7721
*7728
  7721
*7729
  7721
*7760
  7721
*7761
  7721
*7762
  7721
*7763
  7721
*7764
  7721
*7765
  7721
*7766
  7721
*7767
  7721
*7768
  7721
*7769
  7721
*7798
  7721
------------------------------------------------------------------------


[[Page 40069]]


                                   Table 7A.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
                                                       [FY2000 MEDPAR update 03/01 Grouper V18.0 ]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Number        Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           34040          9.0038               2               3               6              12              19
2.......................................            6862          9.9787               3               5               8              12              20
3.......................................               2         43.5000              35              35              52              52              52
4.......................................            6110          7.1570               1               2               5               9              15
5.......................................           93853          3.1665               1               1               2               3               7
6.......................................             365          2.9671               1               1               2               4               6
7.......................................           13063          9.8610               2               4               7              12              20
8.......................................            3725          2.8969               1               1               2               4               7
9.......................................            1632          6.3192               1               3               5               8              13
10......................................           17754          6.5545               2               3               5               8              13
11......................................            3157          4.0744               1               2               3               5               8
12......................................           47063          5.9088               2               3               4               7              11
13......................................            6504          5.1948               2               3               4               6               9
14......................................          321622          5.8761               2               3               5               7              11
15......................................          146291          3.5528               1               2               3               4               7
16......................................           11235          6.0446               2               3               5               7              12
17......................................            3532          3.3061               1               2               3               4               6
18......................................           26608          5.4190               2               3               4               7              10
19......................................            8346          3.6416               1               2               3               5               7
20......................................            5680         10.1768               3               5               8              13              20
21......................................            1324          6.5249               2               3               5               8              13
22......................................            2560          4.8176               1               2               4               6               9
23......................................            9553          4.1807               1               2               3               5               8
24......................................           53313          4.9825               1               2               4               6              10
25......................................           25528          3.2186               1               2               3               4               6
26......................................              33          2.9091               1               1               2               4               6
27......................................            3519          5.0673               1               1               3               6              11
28......................................           11477          6.2222               1               3               5               8              13
29......................................            4545          3.5982               1               2               3               5               7
30......................................               1          1.0000               1               1               1               1               1
31......................................            3576          4.4855               1               2               3               5               8
32......................................            1770          2.5644               1               1               2               3               5
33......................................               1          1.0000               1               1               1               1               1
34......................................           20753          5.0757               1               2               4               6              10
35......................................            5893          3.3743               1               2               3               4               6
36......................................            3217          1.4719               1               1               1               1               2
37......................................            1465          4.0348               1               1               2               5               9
38......................................             102          2.6569               1               1               2               3               5
39......................................             918          1.9379               1               1               1               2               4
40......................................            1561          3.4209               1               1               2               4               7
42......................................            2235          2.2859               1               1               1               3               5
43......................................              85          3.1882               1               2               3               4               6
44......................................            1244          4.9518               2               3               4               6               9
45......................................            2464          3.1717               1               2               3               4               6
46......................................            3102          4.6518               1               2               4               6               9
47......................................            1284          3.2749               1               1               3               4               6
49......................................            2266          4.8010               1               2               3               6               9
50......................................            2507          1.9418               1               1               1               2               3
51......................................             205          2.6927               1               1               1               2               6
52......................................             224          1.9196               1               1               1               2               3
53......................................            2509          3.5787               1               1               2               4               8
54......................................               2          1.5000               1               1               2               2               2
55......................................            1519          2.7340               1               1               1               3               6
56......................................             517          2.7389               1               1               2               3               5
57......................................             712          4.0478               1               1               2               5               9
59......................................             107          2.7850               1               1               2               3               5
60......................................               2          3.5000               2               2               5               5               5
61......................................             234          5.1624               1               1               2               6              13
62......................................               3          1.3333               1               1               1               2               2
63......................................            2955          4.3993               1               2               3               5               9
64......................................            3070          6.1642               1               2               4               8              13
65......................................           34702          2.8444               1               1               2               4               5
66......................................            7035          3.1599               1               1               2               4               6
67......................................             501          3.5768               1               2               3               4               7
68......................................           16708          4.1241               1               2               3               5               7
69......................................            5417          3.2845               1               2               3               4               6
70......................................              24          2.9167               1               2               2               4               5
71......................................              82          3.8049               1               2               3               4               7
72......................................             893          3.5566               1               2               3               4               6
73......................................            6690          4.3988               1               2               3               6               9

[[Page 40070]]

 
75......................................           39476          9.9112               3               5               7              12              19
76......................................           39399         11.3188               3               5               9              14              21
77......................................            2358          4.9165               1               2               4               7              10
78......................................           32319          6.7837               3               4               6               8              11
79......................................          170615          8.4963               3               4               7              11              16
80......................................            8981          5.6562               2               3               5               7              10
81......................................               4         18.2500               3               3               4               8              58
82......................................           62447          6.9403               2               3               5               9              14
83......................................            6598          5.5518               2               3               4               7              10
84......................................            1539          3.3197               1               2               3               4               6
85......................................           20738          6.3135               2               3               5               8              12
86......................................            2115          3.6648               1               2               3               5               7
87......................................           60486          6.2986               1               3               5               8              12
88......................................          395676          5.1294               2               3               4               6               9
89......................................          529122          5.9478               2               3               5               7              11
90......................................           53985          4.1475               2               3               4               5               7
91......................................              57          4.4561               2               2               3               5               9
92......................................           13873          6.3521               2               3               5               8              12
93......................................            1692          4.0969               1               2               3               5               7
94......................................           12158          6.3088               2               3               5               8              12
95......................................            1621          3.7224               1               2               3               5               7
96......................................           62414          4.6281               2               3               4               6               8
97......................................           31618          3.6509               1               2               3               5               7
98......................................              17          4.3529               1               2               3               4               6
99......................................           19205          3.2061               1               1               2               4               6
100.....................................            7656          2.1813               1               1               2               3               4
101.....................................           20236          4.3987               1               2               3               5               9
102.....................................            5196          2.6522               1               1               2               3               5
103.....................................             494         47.2510               9              13              25              61             102
104.....................................           37017         11.3083               3               6               9              14              22
105.....................................           29991          9.2831               4               5               7              11              17
106.....................................            3425         11.4923               5               7              10              14              20
107.....................................           88610         10.3724               5               7               9              12              17
108.....................................            6099         10.2140               3               5               8              13              19
109.....................................           60766          7.6912               4               5               6               9              12
110.....................................           53054          9.2130               2               5               7              11              18
111.....................................            8563          4.7507               1               2               5               6               8
112.....................................           56110          3.6750               1               1               2               5               8
113.....................................           42570         12.2362               3               6               9              15              24
114.....................................            8788          8.4208               2               4               7              11              16
115.....................................           14447          8.1481               1               4               7              11              16
116.....................................          333539          3.6045               1               1               2               5               8
117.....................................            3750          4.1997               1               1               2               5               9
118.....................................            7731          2.6831               1               1               1               3               6
119.....................................            1315          4.8783               1               1               3               6              12
120.....................................           36315          8.1402               1               2               5              11              18
121.....................................          163108          6.3828               2               3               5               8              12
122.....................................           79700          3.6981               1               2               3               5               7
123.....................................           40952          4.5870               1               1               3               6              11
124.....................................          133892          4.3434               1               2               3               5               8
125.....................................           80872          2.7656               1               1               2               4               5
126.....................................            5210         11.7196               3               6               9              15              22
127.....................................          683001          5.2764               2               3               4               7              10
128.....................................            9485          5.6128               2               4               5               7               9
129.....................................            4174          2.7513               1               1               1               3               6
130.....................................           87705          5.6725               2               3               5               7              10
131.....................................           27378          4.2134               1               2               4               6               7
132.....................................          148681          3.0010               1               1               2               4               6
133.....................................            8355          2.3246               1               1               2               3               4
134.....................................           36411          3.2406               1               2               3               4               6
135.....................................            7338          4.5492               1               2               3               6               9
136.....................................            1233          2.7178               1               1               2               3               5
138.....................................          195523          3.9935               1               2               3               5               8
139.....................................           82943          2.5030               1               1               2               3               5
140.....................................           70338          2.6538               1               1               2               3               5
141.....................................           91110          3.6692               1               2               3               5               7
142.....................................           45981          2.6476               1               1               2               3               5
143.....................................          205686          2.1259               1               1               2               3               4
144.....................................           82529          5.3248               1               2               4               7              11
145.....................................            7242          2.7331               1               1               2               3               5

[[Page 40071]]

 
146.....................................           10755         10.3134               5               7               9              12              17
147.....................................            2637          6.4137               3               5               6               8               9
148.....................................          129971         12.2043               5               7              10              15              22
149.....................................           18528          6.5116               4               5               6               8               9
150.....................................           19921         11.2798               4               7              10              14              20
151.....................................            4858          5.8121               2               3               5               8              10
152.....................................            4399          8.1444               3               5               7               9              14
153.....................................            2100          5.3838               3               4               5               7               8
154.....................................           28871         13.1708               4               7              10              16              25
155.....................................            6655          4.2026               1               2               3               6               8
156.....................................               4          7.5000               1               1               5               6              18
157.....................................            7956          5.3910               1               2               4               7              11
158.....................................            4670          2.5362               1               1               2               3               5
159.....................................           16448          4.9962               1               2               4               6              10
160.....................................           11726          2.6594               1               1               2               3               5
161.....................................           11205          4.2062               1               1               3               5               9
162.....................................            7214          1.9211               1               1               1               2               4
163.....................................               7          3.5714               1               1               2               3               4
164.....................................            4857          8.4293               4               5               7              10              15
165.....................................            2086          4.7895               2               3               5               6               8
166.....................................            3559          5.0441               2               2               4               6              10
167.....................................            3316          2.6001               1               2               2               3               5
168.....................................            1235          4.9247               1               2               3               6              10
169.....................................             813          2.3395               1               1               2               3               5
170.....................................           11057         11.1942               2               5               8              14              22
171.....................................            1274          4.6201               1               2               4               6               9
172.....................................           30682          6.9445               2               3               5               9              14
173.....................................            2707          3.6679               1               1               3               5               7
174.....................................          242054          4.7970               2               3               4               6               9
175.....................................           32431          2.9309               1               2               3               4               5
176.....................................           15194          5.2285               2               3               4               6              10
177.....................................            9272          4.5310               2               2               4               6               8
178.....................................            3619          3.0683               1               2               3               4               6
179.....................................           12384          5.9738               2               3               5               7              11
180.....................................           86181          5.3581               2               3               4               7              10
181.....................................           26423          3.4153               1               2               3               4               6
182.....................................          234742          4.3758               1               2               3               5               8
183.....................................           81065          2.9320               1               1               2               4               5
184.....................................              78          2.9487               1               2               2               4               6
185.....................................            4769          4.5280               1               2               3               6               9
186.....................................               3          9.3333               1               1               9              18              18
187.....................................             443          4.0045               1               2               3               5               8
188.....................................           76140          5.5645               1               2               4               7              11
189.....................................           12060          3.1404               1               1               2               4               6
190.....................................              51          6.9608               2               3               4               5               8
191.....................................            8964         13.8146               4               6              10              17              27
192.....................................            1122          6.5294               2               4               6               8              11
193.....................................            5303         12.5218               5               7              10              16              22
194.....................................             721          6.7906               2               4               6               8              12
195.....................................            4350         10.1616               4               6               9              12              17
196.....................................            1166          5.7196               2               4               5               7              10
197.....................................           18895          8.9383               3               5               7              11              16
198.....................................            5786          4.5380               2               3               4               6               8
199.....................................            1725          9.6614               2               4               7              13              21
200.....................................            1081         10.3478               1               3               7              13              23
201.....................................            1413         13.7594               3               6              11              17              27
202.....................................           26168          6.4060               2               3               5               8              13
203.....................................           29251          6.6384               2               3               5               9              13
204.....................................           57757          5.7995               2               3               4               7              11
205.....................................           23128          6.1790               2               3               5               8              12
206.....................................            1970          3.8959               1               2               3               5               7
207.....................................           31072          5.0836               1               2               4               6              10
208.....................................           10149          2.8924               1               1               2               4               6
209.....................................          345519          5.0794               3               3               4               6               8
210.....................................          121933          6.8207               3               4               6               8              11
211.....................................           31780          4.9358               3               4               4               6               7
212.....................................               8         10.5000               1               1               4               9              29
213.....................................            9241          9.0019               2               4               7              11              18
216.....................................            6008          9.6949               2               4               8              12              20
217.....................................           16558         13.2636               3               5               9              16              28

[[Page 40072]]

 
218.....................................           21625          5.4332               2               3               4               7              10
219.....................................           19714          3.2188               1               2               3               4               6
220.....................................               6          4.0000               1               1               3               7               7
223.....................................           13397          2.8551               1               1               2               3               6
224.....................................           11274          1.9346               1               1               2               2               3
225.....................................            5805          4.8558               1               2               3               6              11
226.....................................            5235          6.5958               1               2               4               8              14
227.....................................            4703          2.7053               1               1               2               3               5
228.....................................            2373          3.7981               1               1               2               5               8
229.....................................            1119          2.4781               1               1               2               3               5
230.....................................            2401          5.2603               1               2               3               6              11
231.....................................           12308          4.9551               1               2               3               6              10
232.....................................             811          2.8792               1               1               1               3               7
233.....................................            5175          7.5314               2               3               6              10              15
234.....................................            3204          3.4263               1               1               3               4               7
235.....................................            5095          5.1460               1               2               4               6               9
236.....................................           38644          4.8192               1               3               4               6               9
237.....................................            1698          3.4953               1               2               3               4               6
238.....................................            8028          8.5896               3               4               6              10              16
239.....................................           49412          6.2190               2               3               5               8              12
240.....................................           11462          6.6902               2               3               5               8              13
241.....................................            3138          3.8368               1               2               3               5               7
242.....................................            2455          6.6550               2               3               5               8              13
243.....................................           88444          4.6699               1               2               4               6               9
244.....................................           12282          4.8026               1               2               4               6               9
245.....................................            5158          3.4420               1               2               3               4               6
246.....................................            1402          3.8759               1               2               3               5               7
247.....................................           16979          3.4022               1               1               3               4               7
248.....................................           10612          4.8149               1               2               4               6               9
249.....................................           11655          3.6913               1               1               2               4               8
250.....................................            3495          4.1021               1               2               3               5               7
251.....................................            2432          2.8647               1               1               2               4               5
253.....................................           19997          4.7768               1               3               4               6               9
254.....................................           10514          3.1844               1               2               3               4               6
255.....................................               1          3.0000               3               3               3               3               3
256.....................................            6110          5.0566               1               2               4               6              10
257.....................................           16468          2.7380               1               1               2               3               5
258.....................................           16096          1.9335               1               1               2               2               3
259.....................................            3805          2.6915               1               1               1               2               6
260.....................................            4920          1.4191               1               1               1               2               2
261.....................................            1871          2.2720               1               1               1               3               5
262.....................................             615          4.0065               1               1               3               5               8
263.....................................           23616         11.6630               3               5               8              14              23
264.....................................            4081          7.0034               2               3               5               8              14
265.....................................            3785          6.7974               1               2               4               8              14
266.....................................            2669          3.2345               1               1               2               4               7
267.....................................             233          4.2060               1               1               3               6               9
268.....................................             910          3.5824               1               1               2               4               7
269.....................................            8868          8.2049               2               3               6              10              17
270.....................................            2661          3.4540               1               1               2               4               7
271.....................................           20588          7.1370               2               4               6               9              13
272.....................................            5506          6.1593               2               3               5               8              12
273.....................................            1290          4.0233               1               2               3               5               8
274.....................................            2357          6.5965               1               3               5               8              13
275.....................................             249          4.3373               1               1               3               5               9
276.....................................            1183          4.7101               1               2               4               6               8
277.....................................           88891          5.7267               2               3               5               7              10
278.....................................           30673          4.3084               2               3               4               5               8
279.....................................               3          2.3333               1               1               2               4               4
280.....................................           15826          4.1974               1               2               3               5               8
281.....................................            7203          3.0314               1               1               3               4               6
282.....................................               3          1.6667               1               1               2               2               2
283.....................................            5701          4.5869               1               2               4               6               9
284.....................................            1863          3.0934               1               1               2               4               6
285.....................................            6259         10.2903               3               5               8              13              20
286.....................................            2081          6.4248               2               3               5               7              13
287.....................................            5745         10.5220               3               5               7              12              21
288.....................................            2705          5.7360               2               3               4               6               9
289.....................................            4801          3.0165               1               1               2               3               7
290.....................................            8818          2.3115               1               1               2               2               4

[[Page 40073]]

 
291.....................................              66          1.8333               1               1               1               2               3
292.....................................            5044         10.2399               2               4               8              13              20
293.....................................             385          5.3714               1               2               4               7              11
294.....................................           88615          4.6095               1               2               4               6               9
295.....................................            3318          3.7372               1               2               3               5               7
296.....................................          240055          5.1602               2               2               4               6              10
297.....................................           44040          3.4064               1               2               3               4               6
298.....................................              95          2.9158               1               1               2               4               5
299.....................................            1192          5.3079               1               2               4               7              11
300.....................................           16118          6.1471               2               3               5               8              12
301.....................................            3221          3.6107               1               2               3               4               7
302.....................................            8256          9.0922               4               5               7              10              16
303.....................................           19568          8.4192               4               5               7              10              15
304.....................................           11902          8.7432               2               4               6              11              18
305.....................................            3011          3.6430               1               2               3               5               7
306.....................................            7368          5.6221               1               2               3               8              13
307.....................................            2096          2.2457               1               1               2               3               4
308.....................................            7520          6.2090               1               2               4               8              14
309.....................................            4120          2.2998               1               1               2               3               4
310.....................................           24033          4.4040               1               1               3               6              10
311.....................................            8027          1.8343               1               1               1               2               3
312.....................................            1499          4.4957               1               1               3               6              10
313.....................................             594          2.3300               1               1               1               3               5
314.....................................               1          3.0000               3               3               3               3               3
315.....................................           30085          6.9945               1               1               4               9              16
316.....................................          105482          6.6227               2               3               5               8              13
317.....................................            1536          2.8561               1               1               2               3               6
318.....................................            5627          6.0105               1               3               5               8              12
319.....................................             428          2.7477               1               1               2               3               6
320.....................................          188146          5.3180               2               3               4               6              10
321.....................................           30418          3.7849               1               2               3               5               7
322.....................................              61          4.1475               2               2               3               5               8
323.....................................           17410          3.2221               1               1               2               4               7
324.....................................            7562          1.8803               1               1               1               2               3
325.....................................            8239          3.8229               1               2               3               5               7
326.....................................            2705          2.6699               1               1               2               3               5
327.....................................              11          3.0909               1               1               3               4               5
328.....................................             668          3.6722               1               1               3               5               8
329.....................................              76          2.0000               1               1               1               2               4
331.....................................           46575          5.5475               1               3               4               7              11
332.....................................            4939          3.2909               1               1               2               4               7
333.....................................             290          4.9828               1               2               3               6              10
334.....................................           10491          4.8593               2               3               4               6               8
335.....................................           11916          3.3087               2               2               3               4               5
336.....................................           37713          3.4950               1               2               2               4               7
337.....................................           30390          2.1186               1               1               2               3               3
338.....................................            1232          5.1080               1               2               3               7              11
339.....................................            1628          4.6161               1               1               3               6              11
340.....................................               1          1.0000               1               1               1               1               1
341.....................................            3766          3.0316               1               1               2               3               6
342.....................................             675          3.2207               1               2               2               4               6
344.....................................            3519          2.3743               1               1               1               2               5
345.....................................            1280          3.7914               1               1               2               4               8
346.....................................            4489          5.9082               1               3               4               7              12
347.....................................             366          2.9372               1               1               2               4               6
348.....................................            3077          4.1677               1               2               3               5               8
349.....................................             626          2.5335               1               1               2               3               5
350.....................................            6325          4.4024               1               2               4               5               8
352.....................................             766          3.9621               1               2               3               5               8
353.....................................            2557          6.4490               2               3               5               7              12
354.....................................            7609          5.8406               3               3               4               7              11
355.....................................            5530          3.2790               2               3               3               4               5
356.....................................           25303          2.2920               1               1               2               3               4
357.....................................            5580          8.4925               3               4               7              10              16
358.....................................           20491          4.3133               2               3               3               5               7
359.....................................           30146          2.7284               2               2               3               3               4
360.....................................           16032          2.8550               1               2               2               3               5
361.....................................             386          2.9948               1               1               2               3               5
363.....................................            2875          3.4650               1               2               2               3               7
364.....................................            1667          3.8410               1               1               3               5               8

[[Page 40074]]

 
365.....................................            1737          7.2239               1               3               5               9              16
366.....................................            4468          6.7258               1               3               5               8              14
367.....................................             584          3.1284               1               1               2               4               6
368.....................................            3136          6.4716               2               3               5               8              12
369.....................................            3180          3.2500               1               1               2               4               7
370.....................................            1151          5.9079               3               3               4               5              10
371.....................................            1368          3.6447               2               3               3               4               5
372.....................................             964          3.2811               1               2               2               3               5
373.....................................            3920          2.2487               1               2               2               3               3
374.....................................             130          3.0846               1               2               2               3               4
375.....................................              11          2.2727               1               2               2               2               4
376.....................................             249          3.0843               1               2               2               4               6
377.....................................              51          5.0392               1               1               4               6              12
378.....................................             158          2.4177               1               1               2               3               4
379.....................................             344          3.4506               1               1               2               4               6
380.....................................              60          2.0833               1               1               1               2               5
381.....................................             154          2.5065               1               1               1               3               5
382.....................................              45          1.2889               1               1               1               1               2
383.....................................            1746          3.6174               1               1               2               4               8
384.....................................             121          2.1488               1               1               1               2               4
385.....................................               1          1.0000               1               1               1               1               1
389.....................................              16         13.5000               1               3               6              11              24
390.....................................              14          4.0000               1               2               3               6               7
391.....................................               1          4.0000               4               4               4               4               4
392.....................................            2349          9.6841               3               4               7              12              20
394.....................................            1891          7.1364               1               2               4               8              16
395.....................................           87679          4.4004               1               2               3               6               9
396.....................................              15          4.6667               1               2               4               6               7
397.....................................           17705          5.1893               1               2               4               7              10
398.....................................           17713          5.9510               2               3               5               7              11
399.....................................            1727          3.5634               1               2               3               5               7
400.....................................            6492          9.1288               1               3               6              12              20
401.....................................            5625         11.2775               2               5               9              15              23
402.....................................            1500          4.0933               1               1               3               6               9
403.....................................           32010          8.0846               2               3               6              10              17
404.....................................            4672          4.2609               1               2               3               6               9
406.....................................            2526          9.9224               3               4               7              12              21
407.....................................             722          4.4252               1               2               4               5               8
408.....................................            2193          8.0228               1               2               5              10              18
409.....................................            2831          5.9325               2               3               4               6              12
410.....................................           33654          3.9062               1               2               4               5               6
411.....................................              13          2.3077               1               1               2               2               5
412.....................................              30          2.4000               1               1               2               3               4
413.....................................            6478          7.0869               2               3               5               9              14
414.....................................             780          4.2885               1               2               3               5               9
415.....................................           39078         14.3458               4               6              11              18              28
416.....................................          184735          7.3935               2               4               6               9              14
417.....................................              18          5.0000               1               2               4               7               9
418.....................................           23028          6.1229               2               3               5               7              12
419.....................................           15460          4.7254               2               2               4               6               9
420.....................................            3116          3.4881               1               2               3               4               6
421.....................................           11535          3.7877               1               2               3               5               7
422.....................................              83          3.0482               1               2               3               4               6
423.....................................            7539          8.1108               2               3               6              10              16
424.....................................            1308         13.6338               2               5               9              16              26
425.....................................           15852          3.9953               1               2               3               5               8
426.....................................            4552          4.4512               1               2               3               5               9
427.....................................            1669          4.6207               1               2               3               6               9
428.....................................             854          6.9859               1               2               4               8              14
429.....................................           26786          6.3438               2               3               5               7              12
430.....................................           59892          8.0207               2               3               6              10              16
431.....................................             319          6.4326               1               3               5               7              12
432.....................................             475          4.7684               1               2               3               5               9
433.....................................            5522          3.0996               1               1               2               4               6
434.....................................           23062          5.0233               1               2               4               6               9
435.....................................           15012          4.1096               1               2               3               5               7
436.....................................            3158         12.8322               4               7              11              18              27
437.....................................            8588          8.6778               3               5               8              11              15
439.....................................            1356          8.3857               1               3               5              10              18
440.....................................            5191          9.0326               2               3               6              11              20

[[Page 40075]]

 
441.....................................             604          3.2235               1               1               2               4               7
442.....................................           15588          8.4766               1               3               6              10              18
443.....................................            3738          3.4315               1               1               3               4               7
444.....................................            5303          4.1495               1               2               3               5               8
445.....................................            2450          2.8857               1               1               2               4               5
447.....................................            5497          2.4708               1               1               2               3               5
449.....................................           28365          3.7491               1               1               3               5               8
450.....................................            6935          1.9981               1               1               1               2               4
451.....................................               3          1.3333               1               1               1               2               2
452.....................................           22930          4.8560               1               2               3               6              10
453.....................................            5095          2.7978               1               1               2               3               5
454.....................................            4001          4.5431               1               2               3               5               9
455.....................................             939          2.5751               1               1               2               3               5
461.....................................            3677          4.3723               1               1               2               5              11
462.....................................           13083         11.2728               4               6              10              14              21
463.....................................           22068          4.1282               1               2               3               5               8
464.....................................            6542          3.0011               1               1               2               4               6
465.....................................             248          3.0202               1               1               2               4               6
466.....................................            1741          3.7030               1               1               2               4               8
467.....................................            1137          3.0633               1               1               2               3               6
468.....................................           59766         12.9438               3               6              10              17              26
471.....................................           11720          5.5506               3               4               4               6               9
473.....................................            7663         12.5910               1               3               7              18              32
475.....................................          107894         11.2229               2               5               9              15              22
476.....................................            4142         10.8841               2               5               9              14              21
477.....................................           25336          8.1162               1               3               6              11              17
478.....................................          108852          7.3022               1               3               5               9              15
479.....................................           24100          3.4573               1               1               3               4               7
480.....................................             562         20.9609               7               9              14              25              44
481.....................................             383         24.1253              10              18              22              27              39
482.....................................            5733         12.9843               4               7              10              15              25
483.....................................           42784         39.4479              14              22              33              49              71
484.....................................             331         13.0091               2               6              10              17              26
485.....................................            2959          9.7080               4               5               7              11              18
486.....................................            2017         12.4408               1               5              10              16              25
487.....................................            3506          7.3945               1               3               6              10              15
488.....................................             784         16.9031               3               7              12              22              36
489.....................................           14140          8.4372               2               3               6              10              17
490.....................................            5449          5.3577               1               2               4               6              11
491.....................................           12291          3.4475               2               2               3               4               6
492.....................................            2698         15.6675               3               5               8              25              34
493.....................................           55279          5.7576               1               3               5               7              11
494.....................................           30109          2.4447               1               1               2               3               5
495.....................................             159         15.0503               7               9              12              17              26
496.....................................            1475          9.7349               4               5               7              12              19
497.....................................           22725          6.1720               2               3               5               7              12
498.....................................           21513          3.3043               1               2               3               4               6
499.....................................           31077          4.7330               1               2               3               6               9
500.....................................           44660          2.6198               1               1               2               3               5
501.....................................            2200         10.9600               4               6               8              13              21
502.....................................             585          6.5692               3               4               5               8              11
503.....................................            5631          4.0012               1               2               3               5               7
504.....................................             118         30.5169               9              15              24              41              55
505.....................................             145          3.3517               1               1               1               3               7
506.....................................             931         17.4071               4               8              14              22              36
507.....................................             293          8.3379               2               4               7              11              18
508.....................................             671          7.4918               2               3               5               9              15
509.....................................             177          4.5367               1               2               4               6               9
510.....................................            1650          7.2358               2               3               5               9              15
511.....................................             608          4.8158               1               2               3               6              11
                                         ----------------
                                                11079177
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 40076]]


                                   Table 7B.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
                                                       [FY2000 MEDPAR update 03/01 Grouper V19.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Number        Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           34040          9.0038               2               3               6              12              19
2.......................................            6862          9.9787               3               5               8              12              20
3.......................................               2         43.5000              35              35              52              52              52
4.......................................            6120          7.1526               1               2               5               9              15
5.......................................           93853          3.1665               1               1               2               3               7
6.......................................             365          2.9671               1               1               2               4               6
7.......................................           13283          9.8362               2               4               7              12              20
8.......................................            3821          2.9089               1               1               2               4               7
9.......................................            1631          6.3194               1               3               5               8              13
10......................................           17754          6.5545               2               3               5               8              13
11......................................            3157          4.0744               1               2               3               5               8
12......................................           47063          5.9088               2               3               4               7              11
13......................................            6504          5.1948               2               3               4               6               9
14......................................          321622          5.8761               2               3               5               7              11
15......................................          146291          3.5528               1               2               3               4               7
16......................................           11235          6.0446               2               3               5               7              12
17......................................            3532          3.3061               1               2               3               4               6
18......................................           26608          5.4190               2               3               4               7              10
19......................................            8346          3.6416               1               2               3               5               7
20......................................            5680         10.1768               3               5               8              13              20
21......................................            1324          6.5249               2               3               5               8              13
22......................................            2560          4.8176               1               2               4               6               9
23......................................            9553          4.1807               1               2               3               5               8
24......................................           53313          4.9825               1               2               4               6              10
25......................................           25528          3.2186               1               2               3               4               6
26......................................              33          2.9091               1               1               2               4               6
27......................................            3519          5.0673               1               1               3               6              11
28......................................           11477          6.2222               1               3               5               8              13
29......................................            4545          3.5982               1               2               3               5               7
30......................................               1          1.0000               1               1               1               1               1
31......................................            3576          4.4855               1               2               3               5               8
32......................................            1770          2.5644               1               1               2               3               5
33......................................               1          1.0000               1               1               1               1               1
34......................................           20751          5.0759               1               2               4               6              10
35......................................            5893          3.3743               1               2               3               4               6
36......................................            3217          1.4719               1               1               1               1               2
37......................................            1465          4.0348               1               1               2               5               9
38......................................             102          2.6569               1               1               2               3               5
39......................................             918          1.9379               1               1               1               2               4
40......................................            1561          3.4209               1               1               2               4               7
42......................................            2235          2.2859               1               1               1               3               5
43......................................              85          3.1882               1               2               3               4               6
44......................................            1244          4.9518               2               3               4               6               9
45......................................            2464          3.1717               1               2               3               4               6
46......................................            3102          4.6518               1               2               4               6               9
47......................................            1284          3.2749               1               1               3               4               6
49......................................            2266          4.8010               1               2               3               6               9
50......................................            2507          1.9418               1               1               1               2               3
51......................................             205          2.6927               1               1               1               2               6
52......................................             224          1.9196               1               1               1               2               3
53......................................            2512          3.5760               1               1               2               4               8
54......................................               2          1.5000               1               1               2               2               2
55......................................            1521          2.7331               1               1               1               3               6
56......................................             517          2.7389               1               1               2               3               5
57......................................             712          4.0478               1               1               2               5               9
59......................................             107          2.7850               1               1               2               3               5
60......................................               2          3.5000               2               2               5               5               5
61......................................             234          5.1624               1               1               2               6              13
62......................................               3          1.3333               1               1               1               2               2
63......................................            3039          4.4399               1               2               3               5               9
64......................................            3070          6.1642               1               2               4               8              13
65......................................           34702          2.8444               1               1               2               4               5
66......................................            7035          3.1599               1               1               2               4               6
67......................................             501          3.5768               1               2               3               4               7
68......................................           16804          4.1202               1               2               3               5               7
69......................................            5465          3.2767               1               2               3               4               6
70......................................              24          2.9167               1               2               2               4               5
71......................................              82          3.8049               1               2               3               4               7
72......................................             893          3.5566               1               2               3               4               6
73......................................            6690          4.3988               1               2               3               6               9

[[Page 40077]]

 
75......................................           39476          9.9112               3               5               7              12              19
76......................................           40377         11.4074               3               5               9              14              22
77......................................            2406          5.0000               1               2               4               7              10
78......................................           32319          6.7837               3               4               6               8              11
79......................................          170615          8.4963               3               4               7              11              16
80......................................            8981          5.6562               2               3               5               7              10
81......................................               4         18.2500               3               3               4               8              58
82......................................           62447          6.9403               2               3               5               9              14
83......................................            6598          5.5518               2               3               4               7              10
84......................................            1539          3.3197               1               2               3               4               6
85......................................           20738          6.3135               2               3               5               8              12
86......................................            2115          3.6648               1               2               3               5               7
87......................................           60486          6.2986               1               3               5               8              12
88......................................          395676          5.1294               2               3               4               6               9
89......................................          529122          5.9478               2               3               5               7              11
90......................................           53985          4.1475               2               3               4               5               7
91......................................              57          4.4561               2               2               3               5               9
92......................................           13873          6.3521               2               3               5               8              12
93......................................            1692          4.0969               1               2               3               5               7
94......................................           12158          6.3088               2               3               5               8              12
95......................................            1621          3.7224               1               2               3               5               7
96......................................           62414          4.6281               2               3               4               6               8
97......................................           31618          3.6509               1               2               3               5               7
98......................................              17          4.3529               1               2               3               4               6
99......................................           19205          3.2061               1               1               2               4               6
100.....................................            7656          2.1813               1               1               2               3               4
101.....................................           20236          4.3987               1               2               3               5               9
102.....................................            5196          2.6522               1               1               2               3               5
103.....................................             494         47.2510               9              13              25              61             102
104.....................................           19992         14.2362               6               8              12              17              25
105.....................................           26203          9.7712               4               6               8              11              17
106.....................................            3425         11.4923               5               7              10              14              20
107.....................................           88610         10.3724               5               7               9              12              17
108.....................................            6099         10.2140               3               5               8              13              19
109.....................................           60766          7.6912               4               5               6               9              12
110.....................................           53054          9.2130               2               5               7              11              18
111.....................................            8563          4.7507               1               2               5               6               8
113.....................................           42570         12.2362               3               6               9              15              24
114.....................................            8788          8.4208               2               4               7              11              16
115.....................................           14447          8.1481               1               4               7              11              16
116.....................................          101326          4.5123               1               2               3               6               9
117.....................................            3750          4.1997               1               1               2               5               9
118.....................................            7731          2.6831               1               1               1               3               6
119.....................................            1315          4.8783               1               1               3               6              12
120.....................................           37900          8.5509               1               2               6              11              19
121.....................................          163108          6.3828               2               3               5               8              12
122.....................................           79700          3.6981               1               2               3               5               7
123.....................................           40952          4.5870               1               1               3               6              11
124.....................................          133892          4.3434               1               2               3               5               8
125.....................................           80872          2.7656               1               1               2               4               5
126.....................................            5210         11.7196               3               6               9              15              22
127.....................................          683001          5.2764               2               3               4               7              10
128.....................................            9485          5.6128               2               4               5               7               9
129.....................................            4174          2.7513               1               1               1               3               6
130.....................................           87705          5.6725               2               3               5               7              10
131.....................................           27378          4.2134               1               2               4               6               7
132.....................................          148681          3.0010               1               1               2               4               6
133.....................................            8355          2.3246               1               1               2               3               4
134.....................................           36411          3.2406               1               2               3               4               6
135.....................................            7338          4.5492               1               2               3               6               9
136.....................................            1233          2.7178               1               1               2               3               5
138.....................................          195523          3.9935               1               2               3               5               8
139.....................................           82943          2.5030               1               1               2               3               5
140.....................................           70338          2.6538               1               1               2               3               5
141.....................................           91110          3.6692               1               2               3               5               7
142.....................................           45981          2.6476               1               1               2               3               5
143.....................................          205686          2.1259               1               1               2               3               4
144.....................................           82529          5.3248               1               2               4               7              11
145.....................................            7242          2.7331               1               1               2               3               5
146.....................................           10755         10.3134               5               7               9              12              17

[[Page 40078]]

 
147.....................................            2637          6.4137               3               5               6               8               9
148.....................................          130066         12.2031               5               7              10              15              22
149.....................................           18560          6.5100               4               5               6               8               9
150.....................................           19923         11.2795               4               7              10              14              20
151.....................................            4860          5.8123               2               3               5               8              10
152.....................................            4399          8.1444               3               5               7               9              14
153.....................................            2100          5.3838               3               4               5               7               8
154.....................................           28872         13.1709               4               7              10              16              25
155.....................................            6655          4.2026               1               2               3               6               8
156.....................................               4          7.5000               1               1               5               6              18
157.....................................            7963          5.3929               1               2               4               7              11
158.....................................            4671          2.5359               1               1               2               3               5
159.....................................           16456          4.9981               1               2               4               6              10
160.....................................           11727          2.6592               1               1               2               3               5
161.....................................           11208          4.2057               1               1               3               5               9
162.....................................            7217          1.9216               1               1               1               2               4
163.....................................               7          3.5714               1               1               2               3               4
164.....................................            4857          8.4293               4               5               7              10              15
165.....................................            2086          4.7895               2               3               5               6               8
166.....................................            3559          5.0441               2               2               4               6              10
167.....................................            3316          2.6001               1               2               2               3               5
168.....................................            1361          4.7649               1               2               3               6              10
169.....................................             843          2.3238               1               1               2               3               5
170.....................................           12291         10.9867               2               4               8              14              22
171.....................................            1408          4.5014               1               2               4               6               9
172.....................................           30682          6.9445               2               3               5               9              14
173.....................................            2707          3.6679               1               1               3               5               7
174.....................................          242053          4.7969               2               3               4               6               9
175.....................................           32431          2.9309               1               2               3               4               5
176.....................................           15194          5.2285               2               3               4               6              10
177.....................................            9272          4.5310               2               2               4               6               8
178.....................................            3619          3.0683               1               2               3               4               6
179.....................................           12384          5.9738               2               3               5               7              11
180.....................................           86181          5.3581               2               3               4               7              10
181.....................................           26423          3.4153               1               2               3               4               6
182.....................................          245515          4.3381               1               2               3               5               8
183.....................................           84480          2.9129               1               1               2               4               5
184.....................................              80          2.9500               1               2               2               4               6
185.....................................            4826          4.5089               1               2               3               6               9
186.....................................               3          9.3333               1               1               9              18              18
187.....................................             683          3.9253               1               1               3               5               8
188.....................................           76140          5.5645               1               2               4               7              11
189.....................................           12060          3.1404               1               1               2               4               6
190.....................................              51          6.9608               2               3               4               5               8
191.....................................            8941         13.8186               4               6              10              17              27
192.....................................            1122          6.5294               2               4               6               8              11
193.....................................            5303         12.5218               5               7              10              16              22
194.....................................             721          6.7906               2               4               6               8              12
195.....................................            4350         10.1616               4               6               9              12              17
196.....................................            1166          5.7196               2               4               5               7              10
197.....................................           18895          8.9383               3               5               7              11              16
198.....................................            5786          4.5380               2               3               4               6               8
199.....................................            1725          9.6614               2               4               7              13              21
200.....................................            1081         10.3478               1               3               7              13              23
201.....................................            1431         13.7393               3               6              11              17              27
202.....................................           26168          6.4060               2               3               5               8              13
203.....................................           29251          6.6384               2               3               5               9              13
204.....................................           57757          5.7995               2               3               4               7              11
205.....................................           23128          6.1790               2               3               5               8              12
206.....................................            1970          3.8959               1               2               3               5               7
207.....................................           31072          5.0836               1               2               4               6              10
208.....................................           10149          2.8924               1               1               2               4               6
209.....................................          345519          5.0794               3               3               4               6               8
210.....................................          121933          6.8207               3               4               6               8              11
211.....................................           31780          4.9358               3               4               4               6               7
212.....................................               8         10.5000               1               1               4               9              29
213.....................................            9241          9.0019               2               4               7              11              18
216.....................................            6008          9.6949               2               4               8              12              20
217.....................................           16558         13.2636               3               5               9              16              28
218.....................................           21621          5.4328               2               3               4               7              10

[[Page 40079]]

 
219.....................................           19714          3.2188               1               2               3               4               6
220.....................................               6          4.0000               1               1               3               7               7
223.....................................           13397          2.8551               1               1               2               3               6
224.....................................           11274          1.9346               1               1               2               2               3
225.....................................            5805          4.8558               1               2               3               6              11
226.....................................            5230          6.5887               1               2               4               8              14
227.....................................            4702          2.7052               1               1               2               3               5
228.....................................            2373          3.7981               1               1               2               5               8
229.....................................            1118          2.4785               1               1               2               3               5
230.....................................            2395          5.2551               1               2               3               6              11
231.....................................           11467          4.9383               1               2               3               6              11
232.....................................             811          2.8792               1               1               1               3               7
233.....................................            5159          7.5251               1               3               6              10              15
234.....................................            3186          3.4203               1               1               3               4               7
235.....................................            5095          5.1460               1               2               4               6               9
236.....................................           38644          4.8192               1               3               4               6               9
237.....................................            1698          3.4953               1               2               3               4               6
238.....................................            8028          8.5896               3               4               6              10              16
239.....................................           49410          6.2190               2               3               5               8              12
240.....................................           11462          6.6902               2               3               5               8              13
241.....................................            3138          3.8368               1               2               3               5               7
242.....................................            2455          6.6550               2               3               5               8              13
243.....................................           88325          4.6695               1               2               4               6               9
244.....................................           12281          4.8027               1               2               4               6               9
245.....................................            5158          3.4420               1               2               3               4               6
246.....................................            1402          3.8759               1               2               3               5               7
247.....................................           16979          3.4022               1               1               3               4               7
248.....................................           10612          4.8149               1               2               4               6               9
249.....................................           11431          3.6726               1               1               2               4               8
250.....................................            3495          4.1021               1               2               3               5               7
251.....................................            2432          2.8647               1               1               2               4               5
253.....................................           19997          4.7768               1               3               4               6               9
254.....................................           10514          3.1844               1               2               3               4               6
255.....................................               1          3.0000               3               3               3               3               3
256.....................................            6097          5.0576               1               2               4               6              10
257.....................................           16468          2.7380               1               1               2               3               5
258.....................................           16096          1.9335               1               1               2               2               3
259.....................................            3805          2.6915               1               1               1               2               6
260.....................................            4920          1.4191               1               1               1               2               2
261.....................................            1875          2.2704               1               1               1               3               5
262.....................................             622          3.9807               1               1               3               5               8
263.....................................           23616         11.6630               3               5               8              14              23
264.....................................            4081          7.0034               2               3               5               8              14
265.....................................            3785          6.7974               1               2               4               8              14
266.....................................            2669          3.2345               1               1               2               4               7
267.....................................             233          4.2060               1               1               3               6               9
268.....................................             910          3.5824               1               1               2               4               7
269.....................................            8868          8.2049               2               3               6              10              17
270.....................................            2662          3.4530               1               1               2               4               7
271.....................................           20588          7.1370               2               4               6               9              13
272.....................................            5506          6.1593               2               3               5               8              12
273.....................................            1290          4.0233               1               2               3               5               8
274.....................................            2357          6.5965               1               3               5               8              13
275.....................................             249          4.3373               1               1               3               5               9
276.....................................            1189          4.7258               1               2               4               6               8
277.....................................           88891          5.7267               2               3               5               7              10
278.....................................           30673          4.3084               2               3               4               5               8
279.....................................               3          2.3333               1               1               2               4               4
280.....................................           15826          4.1974               1               2               3               5               8
281.....................................            7203          3.0314               1               1               3               4               6
282.....................................               3          1.6667               1               1               2               2               2
283.....................................            5701          4.5869               1               2               4               6               9
284.....................................            1863          3.0934               1               1               2               4               6
285.....................................            6259         10.2903               3               5               8              13              20
286.....................................            2081          6.4248               2               3               5               7              13
287.....................................            5745         10.5220               3               5               7              12              21
288.....................................            2705          5.7360               2               3               4               6               9
289.....................................            4801          3.0165               1               1               2               3               7
290.....................................            8818          2.3115               1               1               2               2               4
291.....................................              66          1.8333               1               1               1               2               3

[[Page 40080]]

 
292.....................................            4994         10.2367               2               4               8              13              20
293.....................................             385          5.3714               1               2               4               7              11
294.....................................           88615          4.6095               1               2               4               6               9
295.....................................            3318          3.7372               1               2               3               5               7
296.....................................          240050          5.1602               2               2               4               6              10
297.....................................           44040          3.4064               1               2               3               4               6
298.....................................              95          2.9158               1               1               2               4               5
299.....................................            1192          5.3079               1               2               4               7              11
300.....................................           16118          6.1471               2               3               5               8              12
301.....................................            3221          3.6107               1               2               3               4               7
302.....................................            7924          8.8892               4               5               7              10              15
303.....................................           19568          8.4192               4               5               7              10              15
304.....................................           11900          8.7432               2               4               6              11              18
305.....................................            3011          3.6430               1               2               3               5               7
306.....................................            7368          5.6221               1               2               3               8              13
307.....................................            2096          2.2457               1               1               2               3               4
308.....................................            7520          6.2090               1               2               4               8              14
309.....................................            4120          2.2998               1               1               2               3               4
310.....................................           24033          4.4040               1               1               3               6              10
311.....................................            8027          1.8343               1               1               1               2               3
312.....................................            1499          4.4957               1               1               3               6              10
313.....................................             594          2.3300               1               1               1               3               5
314.....................................               1          3.0000               3               3               3               3               3
315.....................................           30492          7.1080               1               1               4               9              16
316.....................................          105482          6.6227               2               3               5               8              13
317.....................................            1536          2.8561               1               1               2               3               6
318.....................................            5627          6.0105               1               3               5               8              12
319.....................................             428          2.7477               1               1               2               3               6
320.....................................          188146          5.3180               2               3               4               6              10
321.....................................           30418          3.7849               1               2               3               5               7
322.....................................              61          4.1475               2               2               3               5               8
323.....................................           17410          3.2221               1               1               2               4               7
324.....................................            7562          1.8803               1               1               1               2               3
325.....................................            8239          3.8229               1               2               3               5               7
326.....................................            2705          2.6699               1               1               2               3               5
327.....................................              11          3.0909               1               1               3               4               5
328.....................................             668          3.6722               1               1               3               5               8
329.....................................              76          2.0000               1               1               1               2               4
331.....................................           46575          5.5475               1               3               4               7              11
332.....................................            4939          3.2909               1               1               2               4               7
333.....................................             290          4.9828               1               2               3               6              10
334.....................................           10491          4.8593               2               3               4               6               8
335.....................................           11916          3.3087               2               2               3               4               5
336.....................................           37713          3.4950               1               2               2               4               7
337.....................................           30390          2.1186               1               1               2               3               3
338.....................................            1232          5.1080               1               2               3               7              11
339.....................................            1628          4.6161               1               1               3               6              11
340.....................................               1          1.0000               1               1               1               1               1
341.....................................            3766          3.0316               1               1               2               3               6
342.....................................             675          3.2207               1               2               2               4               6
344.....................................            3519          2.3743               1               1               1               2               5
345.....................................            1280          3.7914               1               1               2               4               8
346.....................................            4489          5.9082               1               3               4               7              12
347.....................................             366          2.9372               1               1               2               4               6
348.....................................            3077          4.1677               1               2               3               5               8
349.....................................             626          2.5335               1               1               2               3               5
350.....................................            6325          4.4024               1               2               4               5               8
352.....................................             766          3.9621               1               2               3               5               8
353.....................................            2557          6.4490               2               3               5               7              12
354.....................................            7609          5.8406               3               3               4               7              11
355.....................................            5530          3.2790               2               3               3               4               5
356.....................................           25303          2.2920               1               1               2               3               4
357.....................................            5580          8.4925               3               4               7              10              16
358.....................................           20492          4.3132               2               3               3               5               7
359.....................................           30149          2.7284               2               2               3               3               4
360.....................................           16035          2.8549               1               2               2               3               5
361.....................................             386          2.9948               1               1               2               3               5
363.....................................            2875          3.4650               1               2               2               3               7
364.....................................            1666          3.8427               1               1               3               5               8
365.....................................            1737          7.2239               1               3               5               9              16

[[Page 40081]]

 
366.....................................            4468          6.7258               1               3               5               8              14
367.....................................             584          3.1284               1               1               2               4               6
368.....................................            3136          6.4716               2               3               5               8              12
369.....................................            3178          3.2498               1               1               2               4               7
370.....................................            1151          5.9079               3               3               4               5              10
371.....................................            1368          3.6447               2               3               3               4               5
372.....................................             964          3.2811               1               2               2               3               5
373.....................................            3920          2.2487               1               2               2               3               3
374.....................................             130          3.0846               1               2               2               3               4
375.....................................              11          2.2727               1               2               2               2               4
376.....................................             249          3.0843               1               2               2               4               6
377.....................................              51          5.0392               1               1               4               6              12
378.....................................             158          2.4177               1               1               2               3               4
379.....................................             344          3.4506               1               1               2               4               6
380.....................................              60          2.0833               1               1               1               2               5
381.....................................             154          2.5065               1               1               1               3               5
382.....................................              45          1.2889               1               1               1               1               2
383.....................................            1746          3.6174               1               1               2               4               8
384.....................................             121          2.1488               1               1               1               2               4
385.....................................               1          1.0000               1               1               1               1               1
389.....................................              16         13.5000               1               3               6              11              24
390.....................................              14          4.0000               1               2               3               6               7
391.....................................               1          4.0000               4               4               4               4               4
392.....................................            2349          9.6841               3               4               7              12              20
394.....................................            1891          7.1364               1               2               4               8              16
395.....................................           87678          4.4004               1               2               3               6               9
396.....................................              15          4.6667               1               2               4               6               7
397.....................................           17705          5.1893               1               2               4               7              10
398.....................................           17713          5.9510               2               3               5               7              11
399.....................................            1727          3.5634               1               2               3               5               7
400.....................................            6490          9.1307               1               3               6              12              20
401.....................................            5622         11.2782               2               5               9              15              23
402.....................................            1500          4.0933               1               1               3               6               9
403.....................................           31997          8.0849               2               3               6              10              17
404.....................................            4670          4.2621               1               2               3               6               9
406.....................................            2527          9.9201               3               4               7              12              21
407.....................................             723          4.4219               1               2               4               5               8
408.....................................            2196          8.0255               1               2               5              10              18
409.....................................            2831          5.9325               2               3               4               6              12
410.....................................           33654          3.9062               1               2               4               5               6
411.....................................              13          2.3077               1               1               2               2               5
412.....................................              30          2.4000               1               1               2               3               4
413.....................................            6491          7.0875               2               3               5               9              14
414.....................................             782          4.2813               1               2               3               5               9
415.....................................           39080         14.3464               4               6              11              18              28
416.....................................          184735          7.3935               2               4               6               9              14
417.....................................              18          5.0000               1               2               4               7               9
418.....................................           23026          6.1212               2               3               5               7              11
419.....................................           15460          4.7254               2               2               4               6               9
420.....................................            3116          3.4881               1               2               3               4               6
421.....................................           11535          3.7877               1               2               3               5               7
422.....................................              83          3.0482               1               2               3               4               6
423.....................................            7539          8.1108               2               3               6              10              16
424.....................................            1308         13.6338               2               5               9              16              26
425.....................................           15852          3.9953               1               2               3               5               8
426.....................................            4552          4.4512               1               2               3               5               9
427.....................................            1669          4.6207               1               2               3               6               9
428.....................................             854          6.9859               1               2               4               8              14
429.....................................           26786          6.3438               2               3               5               7              12
430.....................................           59892          8.0207               2               3               6              10              16
431.....................................             319          6.4326               1               3               5               7              12
432.....................................             475          4.7684               1               2               3               5               9
433.....................................            5522          3.0996               1               1               2               4               6
439.....................................            1356          8.3857               1               3               5              10              18
440.....................................            5191          9.0326               2               3               6              11              20
441.....................................             604          3.2235               1               1               2               4               7
442.....................................           15588          8.4766               1               3               6              10              18
443.....................................            3743          3.4320               1               1               3               4               7
444.....................................            5303          4.1495               1               2               3               5               8
445.....................................            2450          2.8857               1               1               2               4               5

[[Page 40082]]

 
447.....................................            5497          2.4708               1               1               2               3               5
449.....................................           28365          3.7491               1               1               3               5               8
450.....................................            6934          1.9980               1               1               1               2               4
451.....................................               3          1.3333               1               1               1               2               2
452.....................................           22930          4.8560               1               2               3               6              10
453.....................................            5091          2.7969               1               1               2               3               5
454.....................................            4001          4.5431               1               2               3               5               9
455.....................................             939          2.5751               1               1               2               3               5
461.....................................            3676          4.3708               1               1               2               5              11
462.....................................           13083         11.2728               4               6              10              14              21
463.....................................           22068          4.1282               1               2               3               5               8
464.....................................            6542          3.0011               1               1               2               4               6
465.....................................             248          3.0202               1               1               2               4               6
466.....................................            1741          3.7030               1               1               2               4               8
467.....................................            1137          3.0633               1               1               2               3               6
468.....................................           55027         12.8995               3               6              10              16              26
471.....................................           11720          5.5506               3               4               4               6               9
473.....................................            7663         12.5910               1               3               7              18              32
475.....................................          107894         11.2229               2               5               9              15              22
476.....................................            4151         10.8829               2               5               9              14              21
477.....................................           25363          8.1252               1               3               6              11              17
478.....................................          108182          7.2900               1               3               5               9              15
479.....................................           24051          3.4569               1               1               3               4               7
480.....................................             562         20.9609               7               9              14              25              44
481.....................................             383         24.1253              10              18              22              27              39
482.....................................            5737         12.9796               4               7              10              15              25
483.....................................           42789         39.4482              14              22              33              49              71
484.....................................             331         13.0091               2               6              10              17              26
485.....................................            2959          9.7080               4               5               7              11              18
486.....................................            2017         12.4408               1               5              10              16              25
487.....................................            3506          7.3945               1               3               6              10              15
488.....................................             784         16.9031               3               7              12              22              36
489.....................................           14140          8.4372               2               3               6              10              17
490.....................................            5454          5.3577               1               2               4               6              11
491.....................................           12291          3.4475               2               2               3               4               6
492.....................................            2698         15.6675               3               5               8              25              34
493.....................................           55279          5.7576               1               3               5               7              11
494.....................................           30109          2.4447               1               1               2               3               5
495.....................................             159         15.0503               7               9              12              17              26
496.....................................            1504          9.7088               4               5               7              12              19
497.....................................           17585          6.5739               3               4               5               7              11
498.....................................           12931          4.1718               2               3               4               5               6
499.....................................           30519          4.7011               1               2               3               6               9
500.....................................           44330          2.6104               1               1               2               3               5
501.....................................            2200         10.9600               4               6               8              13              21
502.....................................             585          6.5692               3               4               5               8              11
503.....................................            5630          4.0014               1               2               3               5               7
504.....................................             118         30.5169               9              15              24              41              55
505.....................................             145          3.3517               1               1               1               3               7
506.....................................             931         17.4071               4               8              14              22              36
507.....................................             293          8.3379               2               4               7              11              18
508.....................................             671          7.4918               2               3               5               9              15
509.....................................             177          4.5367               1               2               4               6               9
510.....................................            1650          7.2358               2               3               5               9              15
511.....................................             608          4.8158               1               2               3               6              11
512.....................................             340         13.8971               7               8              11              16              25
513.....................................             115         10.6000               6               7               8              11              19
514.....................................           17025          7.8702               2               3               6              10              16
515.....................................            3788          5.9060               1               1               4               8              13
516.....................................           68886          4.7702               2               3               4               6               9
517.....................................          171423          2.6737               1               1               2               3               6
518.....................................           48733          3.5023               1               1               2               4               8
519.....................................            6359          5.1030               1               2               3               6              12
520.....................................            9489          2.1653               1               1               2               3               4
521.....................................           28014          5.9437               2               3               4               7              12
522.....................................            6852          9.4658               3               5               8              12              20
523.....................................           14954          4.0942               1               2               3               5               7
                                         ----------------
                                                11094323
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 40083]]


 Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban
              and Rural Hospitals (Case Weighted) July 2001
------------------------------------------------------------------------
                         State                           Urban    Rural
------------------------------------------------------------------------
ALABAMA...............................................    0.343    0.410
ALASKA................................................    0.417    0.697
ARIZONA...............................................    0.355    0.493
ARKANSAS..............................................    0.466    0.445
CALIFORNIA............................................    0.339    0.432
COLORADO..............................................    0.422    0.577
CONNECTICUT...........................................    0.497    0.506
DELAWARE..............................................    0.511    0.450
DISTRICT OF COLUMBIA..................................    0.421  .......
FLORIDA...............................................    0.351    0.370
GEORGIA...............................................    0.461    0.469
HAWAII................................................    0.412    0.549
IDAHO.................................................    0.541    0.561
ILLINOIS..............................................    0.404    0.501
INDIANA...............................................    0.524    0.533
IOWA..................................................    0.486    0.613
KANSAS................................................    0.415    0.637
KENTUCKY..............................................    0.479    0.492
LOUISIANA.............................................    0.401    0.491
MAINE.................................................    0.614    0.540
MARYLAND..............................................    0.759    0.819
MASSACHUSETTS.........................................    0.511    0.571
MICHIGAN..............................................    0.459    0.563
MINNESOTA.............................................    0.493    0.592
MISSISSIPPI...........................................    0.452    0.446
MISSOURI..............................................    0.404    0.475
MONTANA...............................................    0.537    0.588
NEBRASKA..............................................    0.448    0.610
NEVADA................................................    0.306    0.503
NEW HAMPSHIRE.........................................    0.549    0.585
NEW JERSEY............................................    0.394  .......
NEW MEXICO............................................    0.466    0.491
NEW YORK..............................................    0.524    0.607
NORTH CAROLINA........................................    0.517    0.463
NORTH DAKOTA..........................................    0.620    0.655
OHIO..................................................    0.500    0.568
OKLAHOMA..............................................    0.409    0.492
OREGON................................................    0.614    0.598
PENNSYLVANIA..........................................    0.398    0.526
PUERTO RICO...........................................    0.486    0.584
RHODE ISLAND..........................................    0.510  .......
SOUTH CAROLINA........................................    0.440    0.463
SOUTH DAKOTA..........................................    0.529    0.640
TENNESSEE.............................................    0.438    0.453
TEXAS.................................................    0.401    0.493
UTAH..................................................    0.497    0.582
VERMONT...............................................    0.572    0.599
VIRGINIA..............................................    0.459    0.496
WASHINGTON............................................    0.582    0.639
WEST VIRGINIA.........................................    0.568    0.527
WISCONSIN.............................................    0.524    0.613
WYOMING...............................................    0.523    0.717
------------------------------------------------------------------------


    Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
                           Weighted) July 2001
------------------------------------------------------------------------
                             State                                Ratio
------------------------------------------------------------------------
ALABAMA........................................................    0.044
ALASKA.........................................................    0.058
ARIZONA........................................................    0.038
ARKANSAS.......................................................    0.049
CALIFORNIA.....................................................    0.034
COLORADO.......................................................    0.045
CONNECTICUT....................................................    0.036
DELAWARE.......................................................    0.051
DISTRICT OF COLUMBIA...........................................    0.035
FLORIDA........................................................    0.043
GEORGIA........................................................    0.051
HAWAII.........................................................    0.038
IDAHO..........................................................    0.046
ILLINOIS.......................................................    0.040
INDIANA........................................................    0.056
IOWA...........................................................    0.049
KANSAS.........................................................    0.050
KENTUCKY.......................................................    0.046
LOUISIANA......................................................    0.047
MAINE..........................................................    0.040
MARYLAND.......................................................    0.013
MASSACHUSETTS..................................................    0.053
MICHIGAN.......................................................    0.044
MINNESOTA......................................................    0.047
MISSISSIPPI....................................................    0.044
MISSOURI.......................................................    0.044
MONTANA........................................................    0.053
NEBRASKA.......................................................    0.054
NEVADA.........................................................    0.030
NEW HAMPSHIRE..................................................    0.061
NEW JERSEY.....................................................    0.036
NEW MEXICO.....................................................    0.045
NEW YORK.......................................................    0.051
NORTH CAROLINA.................................................    0.046
NORTH DAKOTA...................................................    0.074
OHIO...........................................................    0.047
OKLAHOMA.......................................................    0.046
OREGON.........................................................    0.046
PENNSYLVANIA...................................................    0.039
PUERTO RICO....................................................    0.045
RHODE ISLAND...................................................    0.029
SOUTH CAROLINA.................................................    0.046
SOUTH DAKOTA...................................................    0.059
TENNESSEE......................................................    0.048
TEXAS..........................................................    0.046
UTAH...........................................................    0.047
VERMONT........................................................    0.052
VIRGINIA.......................................................    0.055
WASHINGTON.....................................................    0.063
WEST VIRGINIA..................................................    0.045
WISCONSIN......................................................    0.051
WYOMING........................................................    0.065
------------------------------------------------------------------------

Appendix A--Regulatory Impact Analysis

I. Introduction

    We generally prepare a regulatory flexibility analysis that is 
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 
through 612), unless we certify that a final rule would not have a 
significant economic impact on a substantial number of small entities. 
For purposes of the RFA, we consider all hospitals to be small 
entities. We estimate the total impact of these changes for FY 2002 
payments compared to FY 2001 payments to be approximately a $1.9 
billion increase. As such, this final rule is a major rule as defined 
in 5 U.S.C. 804(2). Therefore, we have prepared an impact analysis for 
this final rule.
    Also, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis for any final rule that may have a 
significant impact on the operations of a substantial number of small 
rural hospitals. Such an analysis must conform to the provisions of 
section 603 of the RFA. For purposes of section 1102(b) of the Act, we 
define a small rural hospital as a hospital with fewer than 100 beds 
that is located outside of a Metropolitan Statistical Area (MSA) or New 
England County Metropolitan Area (NECMA). Section 601(g) of the Social 
Security Amendments of 1983 (Public Law 98-21) designated hospitals in 
certain New England counties as belonging to the adjacent NECMA. Thus, 
for purposes of the hospital inpatient prospective payment systems, we 
classify these hospitals as urban hospitals.
    It is clear that the changes being made in this document would 
affect both a substantial number of small rural hospitals as well as 
other classes of hospitals, and the effects on some may be significant. 
Therefore, the discussion below, in combination with the rest of this 
final rule, constitutes a combined regulatory impact analysis and 
regulatory flexibility analysis.
    We have reviewed this final rule under the threshold criteria of 
Executive Order 13132, Federalism, and have determined that the final 
rule will not have any negative impact on the rights, roles, and 
responsibilities of State, local, or tribal governments.
    Section 202 of the Unfunded Mandate Reform Act of 1995 (Public Law 
104-4) also requires that agencies assess anticipated costs and 
benefits before issuing any final rule that has been preceded by a 
final rule that may result in an expenditure in any one year by State, 
local, or tribal governments, in the aggregate, or by the private 
sector, of $110 million. This final rule would not mandate any 
requirements for State, local, or tribal governments.
    In accordance with the provisions of Executive Order 12866, this 
final rule was reviewed by the Office of Management and Budget.

II. Changes in the Final Rule

    Since we published the proposed rule, the market basket estimates 
for hospitals subject to the inpatient prospective payment system and 
hospitals and units excluded from the system have both risen by 0.2 
percentage points. As a result, the updates are 0.2 percentage points 
higher than the updates reflected in the impact analysis for the 
proposed rule. With the exception of these changes, we are generally 
implementing the policy and

[[Page 40084]]

statutory provisions discussed in the proposed rule.

III. Impact Analysis for CMS-1131-F and CMS-1178-F

    As noted previously, this final rule contains provisions 
implemented in two interim final rules with comment periods. The first, 
published August 1, 2000 (65 FR 47026), implemented, or conformed the 
regulations to, certain statutory provisions relating to Medicare 
payments to hospitals for inpatient services that were contained in 
Public Law 106-113. The second, published June 13, 2001 (66 FR 32172), 
implemented, or conformed the regulations to, certain statutory 
provisions relating to Medicare payments to hospitals for inpatient 
services that were contained in Public Law 106-554.
    As described in the preamble to this final rule, with the exception 
of minor changes to the process for receiving, reviewing, and approving 
new Medicare-dependent small rural hospitals (MDHs), we are not 
changing the policies described in those interim final rules with 
comment period. Therefore, the reader should refer to the impact 
analyses contained in those interim final rules for a discussion of the 
impacts of these changes. For the impact analysis in the August 1, 2000 
interim final rule, the reader should refer to page 47043. For the 
impact analysis in the June 13, 2001 interim final rule, the reader 
should refer to page 32184.

IV. Limitations of Our Analysis

    As has been the case in our previously published regulatory impact 
analyses, the following quantitative analysis presents the projected 
effects of our proposed policy changes, including statutory changes 
effective for FY 2002, on various hospital groups. We estimate the 
effects of individual policy changes by estimating payments per case 
while holding all other payment policies constant. We use the best data 
available, but we do not attempt to predict behavioral responses to our 
policy changes, and we do not make adjustments for future changes in 
such variables as admissions, lengths of stay, or case-mix. We received 
two comments on the impact analysis for our May 4, 2001 proposed rule.
    Comment: One commenter, who was unable to reconcile the 
standardized amounts for FY 2002 proposed in the May 4, 2001 Federal 
Register with the standardized amounts published for FY 2001 (65 FR 
47126 and 66 FR 32176), expressed concern with the level of detail 
provided by the impact analysis and requested a breakdown of the 
changes reflected in Column 8 of Table 1. The commenter also requested 
that we release the complete data so that hospitals could evaluate all 
the proposed FY 2002 policy changes on their own.
    Response: As we stated in the proposed rule, column 8 compares our 
estimate of payments per case, incorporating all changes reflected in 
this final rule for FY 2002 (including statutory changes), to our 
estimate of payments per case in FY 2001. It includes the effects of 
the 2.75 percent update to the standardized amounts and the hospital-
specific rates for MDHs and SCHs. It also reflects the 1.1 percentage 
point difference between the projected percentage of outlier payments 
in FY 2001 (5.1 percent of total DRG payments) and the current estimate 
of the percentage of actual outlier payments in FY 2001 (6.2 percent), 
as described in the introduction to this Appendix and the Addendum to 
this final rule. Additionally, there are differences resulting from the 
increased number of hospitals receiving DSH payments under Section 211 
of Public Law 106-554 and from the increase in SCH rebasing to a 1996 
blended rate. There are also interactive effects among the various 
factors comprising the payment system that we are not able to isolate. 
For these reasons, the values in column 7 may not equal the sum of the 
changes in columns 5 and 6, plus the other impacts that we are able to 
identify. Since we explain the update for FY 2002 in section II. of the 
Addendum of this final rule, and since the impact of those changes are 
the same for all types of hospitals, we do not believe it is necessary 
to isolate that change in a separate impact column. Also, we would like 
to note that all of the data used by us in the impact analysis are 
available to the public. Our impact file is posted on our website 
following the publication of each proposed and final rule. For 
information on obtaining the MedPAR file, the Provider-Specific File, 
and the cost report files on which all of our analysis is based, we 
refer the reader to section VIII. of this final rule.
    Comment: One commenter noted that, in the proposed rule, the budget 
neutrality factor in footnote 6 of Table 1 was printed as 0.992394 
while the same factor was printed as 0.992493 on page 22872 and asked 
which factor was correct.
    Response: Footnote 6 to Table 1 in the proposed rule contained a 
typographical error. The budget neutrality factor used in the proposed 
rule was 0.992493 and was printed correctly on page 22872 of the 
proposed rule.

V. Hospitals Included in and Excluded From the Prospective Payment 
System

    The prospective payment systems for hospital inpatient operating 
and capital-related costs encompass nearly all general, short-term, 
acute care hospitals that participate in the Medicare program. There 
were 48 Indian Health Service hospitals in our database, which we 
excluded from the analysis due to the special characteristics of the 
prospective payment method for these hospitals. We also exclude 
critical access hospitals (CAHs) from our analysis, due to the special 
characteristics of these hospitals. Among other short-term, acute care 
hospitals, only the 68 such hospitals in Maryland remain excluded from 
the prospective payment system under the waiver at section 1814(b)(3) 
of the Act. Thus, as of July 2001, we have included 4,795 hospitals in 
our analysis. This represents about 80 percent of all Medicare-
participating hospitals. The majority of this impact analysis focuses 
on this set of hospitals.
    The remaining 20 percent are specialty hospitals that are excluded 
from the prospective payment system and continue to be paid on the 
basis of their reasonable costs (subject to a rate-of-increase ceiling 
on their inpatient operating costs per discharge). These hospitals 
include psychiatric, rehabilitation, long-term care, children's, and 
cancer hospitals. The impacts of our final policy changes on these 
hospitals are discussed below.

VI. Impact on Excluded Hospitals and Units

    As of July 2001, there were 1,064 specialty hospitals excluded from 
the prospective payment system and instead paid on a reasonable cost 
basis subject to the rate-of-increase ceiling under Sec. 413.40. Broken 
down by specialty, there were 507 psychiatric, 210 rehabilitation, 260 
long-term care, 77 children's, and 10 cancer hospitals. In addition, 
there were 1,446 psychiatric units and 926 rehabilitation units in 
hospitals otherwise subject to the prospective payment system. These 
excluded units are also paid in accordance with Sec. 413.40. Under 
Sec. 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable 
to the 68 specialty hospitals and units in Maryland that are paid in 
accordance with the waiver at section 1814(b)(3) of the Act.
    As required by section 1886(b)(3)(B) of the Act, the update factor 
applicable to the rate-of-increase limit for excluded

[[Page 40085]]

hospitals and units for FY 2002 would be between 0.8 and 3.3 percent, 
or 0 percent, depending on the hospital's or unit's costs in relation 
to its limit for the most recent cost reporting period for which 
information is available.
    The impact on excluded hospitals and units of the update in the 
rate-of-increase limit depends on the cumulative cost increases 
experienced by each excluded hospital or unit since its applicable base 
period. For excluded hospitals and units that have maintained their 
cost increases at a level below the percentage increases in the rate-
of-increase limits since their base period, the major effect will be on 
the level of incentive payments these hospitals and units receive. 
Conversely, for excluded hospitals and units with per-case cost 
increases above the cumulative update in their rate-of-increase limits, 
the major effect will be the amount of excess costs that would not be 
reimbursed.
    We note that, under Sec. 413.40(d)(3), an excluded hospital or unit 
whose costs exceed 110 percent of its rate-of-increase limit receives 
its rate-of-increase limit plus 50 percent of the difference between 
its reasonable costs and 110 percent of the limit, not to exceed 110 
percent of its limit. In addition, under the various provisions set 
forth in Sec. 413.40, certain excluded hospitals and units can obtain 
payment adjustments for justifiable increases in operating costs that 
exceed the limit. At the same time, however, by generally limiting 
payment increases, we continue to provide an incentive for excluded 
hospitals and units to restrain the growth in their spending for 
patient services.

VII. Graduate Medical Education Impact

A. National Average Per Resident Amount (PRA)

    As discussed in detail in section IV.H.2. of this proposed rule, we 
proposed to implement section 511 of Public Law 106-554, which 
increased the floor of the locality-adjusted national average (PRA for 
the purposes of computing direct GME payments for cost reporting 
periods beginning during FY 2002. The national average PRA payment 
methodology, as provided in section 311 of Public Law 106-113, 
establishes a ``floor'' and ``ceiling'' based on a locality-adjusted, 
updated national average PRA for cost reporting periods beginning on or 
after October 1, 2000 and before October 1, 2005. Section 511 of Public 
Law 106-554 increased the floor from 70 percent to equal 85 percent of 
a locality-adjusted national average PRA for FY 2002.
    For this final rule, we have calculated an estimated impact of this 
policy on teaching hospitals' PRAs for FY 2002, making assumptions 
about update factors and geographic adjustment factors (GAF) for each 
hospital. Generally, using FY 1997 data, we calculated a floor based on 
70 percent of the national average PRA and a floor based on 85 percent 
of the national average PRA. We then determined the amount of direct 
GME payments that would have been paid had the floor remained at 70 
percent of the national average PRA. Next, we determined the amount of 
direct GME payments that would be paid with the floor increased to 
equal 85 percent of the national average PRA. We subtracted the 
difference between the two and inflated the difference to FY 2002 to 
determine the impact of this provision.
    The figures we used in this impact, except for the FY 1997 weighted 
PRA of $68,464, are estimations and are for demonstrative purposes 
only. Hospitals must use the methodology stated in section IV.H. of 
this final rule to revise (if appropriate) their individual PRAs.
    In calculating this impact, we used Medicare cost report data for 
all cost reports ending in FY 1997. We excluded hospitals that file 
manual cost reports because we did not have access to their Medicare 
utilization data. We also excluded all teaching hospitals in Maryland, 
because these hospitals are paid on a Medicare waiver outside of the 
prospective payment system, and those hospitals' PRAs do not determine 
their level of direct GME payments. For hospitals that had two cost 
reporting periods ending in FY 1997, we used the later of the two 
periods. A total of 1,231 teaching hospitals were included in the 
analysis.
    Using the FY 1997 weighted average PRA of $68,464, we determined an 
85 percent floor of $58,194 for FY 1997. We then determined that, for 
cost reporting periods ending in FY 1997, approximately 562 hospitals 
had PRAs that were below $58,194 (336 hospitals of these hospitals had 
PRAs that were below the 70-percent floor, and 226 hospitals had PRAs 
that were above the 70-percent floor but below the 85-percent floor). 
The estimated total cost to the Medicare program in FY 2002 of 
replacing the PRAs of the 562 hospitals with the 85-percent floor is 
$105.3 million.

B. Closed Training Programs or Hospitals That Close Their Training 
Programs

    As discussed in IV.H.5, of the preamble of this final rule, we are 
allowing a hospital to receive a temporary adjustment to its FTE cap to 
reflect residents added because of the closure of another hospital's 
GME program if the hospital that closed its program agrees to 
temporarily reduce its FTE cap. We have calculated an estimated impact 
on the Medicare program for FY 2002 as a result of this policy. We used 
the best available cost report data from the FY 1997 HCRIS in our 
analysis.
    We estimate that approximately 5 to 10 programs, each with an 
average of 25 residents, close each year without advance warning, 
displacing the residents before they complete their training. 
Therefore, the number of residents displaced each year could be between 
125 and 250. We estimated the impact of this change based on direct GME 
and IME payment amounts in FY 1997 to determine a total GME amount and 
updated the total with the CPI-U for FY 2002. At most, the estimated 
impact for this provision for FY 2002 is moving payments of between $10 
and $20 million among different hospitals. This would result from 
redirecting these payments from the hospital that closed its program to 
the hospital(s) that takes on the residents.

VIII. Quantitative Impact Analysis of the Final Policy Changes 
Under the Prospective Payment System for Operating Costs

A. Basis and Methodology of Estimates

    In this final rule, we are announcing policy changes and payment 
rate updates for the prospective payment systems for operating and 
capital-related costs. We have prepared separate impact analyses of the 
final changes to each system. This section deals with changes to the 
operating prospective payment system.
    The data used in developing the quantitative analyses presented 
below are taken from the March 2001 update of the FY 2000 MedPAR file 
and the most current Provider Specific File that is used for payment 
purposes. Although the analyses of the changes to the operating 
prospective payment system do not incorporate cost data, the most 
recently available hospital cost report data were used to categorize 
hospitals. Our analysis has several qualifications. First, we do not 
make adjustments for behavioral changes that hospitals may adopt in 
response to these final policy changes. Second, due to the

[[Page 40086]]

interdependent nature of the prospective payment system, it is very 
difficult to precisely quantify the impact associated with each final 
change. Third, we draw upon various sources for the data used to 
categorize hospitals in the tables. In some cases, particularly the 
number of beds, there is a fair degree of variation in the data from 
different sources. We have attempted to construct these variables with 
the best available sources overall. For individual hospitals, however, 
some miscategorizations are possible.
    Using cases from the March, 2001 update of the FY 2000 MedPAR file, 
we simulated payments under the operating prospective payment system 
given various combinations of payment parameters. Any short-term, acute 
care hospitals not paid under the general prospective payment systems 
(Indian Health Service hospitals and hospitals in Maryland) are 
excluded from the simulations. Payments under the capital prospective 
payment system, or payments for costs other than inpatient operating 
costs, are not analyzed here. Estimated payment impacts of FY 2002 
policy changes to the capital prospective payment system are discussed 
in section IX. of this Appendix.
    The changes discussed separately below are the following:
     The effects of the annual reclassification of diagnoses 
and procedures and the recalibration of the diagnosis-related group 
(DRG) relative weights required by section 1886(d)(4)(C) of the Act.
     The effects of changes in hospitals' wage index values 
reflecting wage data from hospitals' cost reporting periods beginning 
during FY 1998, compared to the FY 1997 wage data.
     The effects of our final policy to increase the accuracy 
of the wage index calculation by changing the overhead allocation 
method used so that the salaries and hours of lower-wage, overhead 
employees and the overhead wage-related costs associated with the 
excluded areas of the hospital are more accurately removed when 
calculating the overhead costs attributable to wages.
     The effects of our final policy to include the contract 
labor costs of laboratories and pharmacies from Worksheet S-3 Part II 
Lines 9.01 and 9.02 in the wage index calculation.
     The combined effects of our changes to the wage index data 
and calculations and the changes in the DRG recalibration.
     The effects of geographic reclassifications by the 
Medicare Geographic Classification Review Board (MGCRB) that will be 
effective in FY 2002.
     The effects of our new policy to hold-harmless other 
hospitals in an urban area where certain hospitals are reclassified 
elsewhere by including the wage data of reclassified hospitals in their 
geographic area as well as the area to which they are reclassified.
     The total change in payments based on FY 2002 policies 
relative to payments based on FY 2001 policies.
    To illustrate the impacts of the FY 2002 final changes, our 
analysis begins with a FY 2002 baseline simulation model using: the FY 
2001 DRG GROUPER (version 18.0); the FY 2001 wage index; and no MGCRB 
reclassifications. Outlier payments are set at 5.1 percent of total DRG 
plus outlier payments.
    Each final and statutory policy change is then added incrementally 
to this baseline model, finally arriving at an FY 2002 model 
incorporating all of the changes. This allows us to isolate the effects 
of each change.
    Our final comparison illustrates the percent change in payments per 
case from FY 2001 to FY 2002. Five factors have significant impacts 
here. The first is the update to the standardized amounts. In 
accordance with section 1886(d)(3)(A)(iv) of the Act, as amended by 
section 301 of Public Law 106-554, we updated the large urban and the 
other areas average standardized amounts for FY 2002 using the most 
recently forecasted hospital market basket increase for FY 2002 of 3.3 
percent minus 0.55 percentage points (for an update of 2.75 percent). 
Under section 1886(b)(3) of the Act, the updates to the hospital-
specific amounts for sole community hospitals (SCHs) and for MDHs are 
equal to the market basket increase of 3.3 percent minus 0.55 
percentage points (for an update of 2.75 percent).
    A second significant factor that impacts changes in hospitals' 
payments per case from FY 2001 to FY 2002 is the change in MGCRB status 
from one year to the next. That is, hospitals reclassified in FY 2001 
that are no longer reclassified in FY 2002 may have a negative payment 
impact going from FY 2001 to FY 2002; conversely, hospitals not 
reclassified in FY 2001 that are reclassified in FY 2002 may have a 
positive impact. In some cases, these impacts can be quite substantial, 
so if a relatively small number of hospitals in a particular category 
lose their reclassification status, the percentage change in payments 
for the category may be below the national mean. This effect may be 
alleviated somewhat by section 304(a) of Public Law 106-554, which 
provided that reclassifications for purposes of the wage index are for 
a 3 year period.
    A third significant factor is that we currently estimate that 
actual outlier payments during FY 2001 will be 6.2 percent of actual 
total DRG payments. When the FY 2001 final rule was published, we 
projected FY 2001 outlier payments would be 5.1 percent of total DRG 
plus outlier payments; the standardized amounts were offset 
correspondingly. The effects of the higher than expected outlier 
payments during FY 2001 (as discussed in the Addendum to this final 
rule) are reflected in the analyses below comparing our current 
estimates of FY 2001 payments per case to estimated FY 2002 payments 
per case.
    Fourth, section 213 of Public Law 106-554 provided that all SCHs 
may receive payment on the basis of their costs per case during their 
cost reporting period that began during 1996. For FY 2002, eligible 
SCHs that are rebased receive a hospital-specific rate comprised of the 
greater of 50-percent of the higher of their FY 1982 or FY 1987 
hospital-specific rate or 50-percent of the federal rate, and 50-
percent of their FY 1996 hospital-specific rate.
    Fifth, sections 302 and 303 of Public Law 106-554 affect payments 
for indirect medical education (IME) and disproportionate share 
hospitals (DSH), respectively. These sections increased IME and DSH 
payments during FY 2001 (effective with discharges on or after April 1, 
2001). For FY 2002, section 302 established IME payments at the same 
level as FY 2001 (6.5 percent), and section 303 established DSH 
payments at the adjustment the hospital would otherwise receive minus 3 
percent.
    Table I demonstrates the results of our analysis. The table 
categorizes hospitals by various geographic and special payment 
consideration groups to illustrate the varying impacts on different 
types of hospitals. The top row of the table shows the overall impact 
on the 4,795 hospitals included in the analysis. This number is 93 
fewer hospitals than were included in the impact analysis in the FY 
2001 final rule (65 FR 47191).
    The next four rows of Table I contain hospitals categorized 
according to their geographic location (all urban (which is further 
divided into large urban and other urban) and rural). There are 2,704 
hospitals located in urban areas (MSAs or NECMAs) included in our 
analysis. Among these, there are 1,561 hospitals located in large urban 
areas (populations over 1 million), and 1,143 hospitals in other urban 
areas (populations of 1 million or fewer). In

[[Page 40087]]

addition, there are 2,091 hospitals in rural areas. The next two 
groupings are by bed-size categories, shown separately for urban and 
rural hospitals. The final groupings by geographic location are by 
census divisions, also shown separately for urban and rural hospitals.
    The second part of Table I shows hospital groups based on 
hospitals' FY 2002 payment classifications, including any 
reclassifications under section 1886(d)(10) of the Act. For example, 
the rows labeled urban, large urban, other urban, and rural show that 
the number of hospitals paid based on these categorizations (after 
consideration of geographic reclassifications) are 2,746, 1,632, 1,114, 
and 2,049, respectively.
    The next three groupings examine the impacts of the final changes 
on hospitals grouped by whether or not they have residency programs 
(teaching hospitals that receive an IME adjustment) or receive DSH 
payments, or some combination of these two adjustments. There are 3,668 
non-teaching hospitals in our analysis, 890 teaching hospitals with 
fewer than 100 residents, and 237 teaching hospitals with 100 or more 
residents.
    In the DSH categories, hospitals are grouped according to their DSH 
payment status, and whether they are considered urban or rural after 
MGCRB reclassifications. Hospitals in the rural DSH categories, 
therefore, represent hospitals that were not reclassified for purposes 
of the standardized amount or for purposes of the DSH adjustment. (They 
may, however, have been reclassified for purposes of the wage index.) 
We note that section 211 of Public Law 106-554 reduced the qualifying 
DSH threshold to 15 percent for all hospitals (this threshold 
previously applied to urban hospitals with 100 or more beds and rural 
hospitals with 500 or more beds). Consequently, many more hospitals 
qualify for DSH. In the FY 2001 final rule, there were 3,070 hospitals 
that did not receive a DSH adjustment (65 FR 47192). In Table I, the 
number of hospitals that did not receive a DSH adjustment declines to 
1,879. The number of urban hospitals with fewer than 100 beds receiving 
DSH increases from 72 prior to section 211 to 316 after its 
implementation. Among rural hospitals with fewer than 100 beds, 103 
received DSH prior to section 211; for FY 2002 that number increases to 
454.
    The next category groups hospitals considered urban after 
geographic reclassification, in terms of whether they receive the IME 
adjustment, the DSH adjustment, both, or neither.
    The next five rows examine the impacts of the final changes on 
rural hospitals by special payment groups (SCHs, rural referral centers 
(RRCs), and MDHs), as well as rural hospitals not receiving a special 
payment designation. The RRCs (165), SCHs (680), MDHs (329), and SCH 
and RRCs (70) shown here were not reclassified for purposes of the 
standardized amount. There are 15 RRCs, 1 MDH, 4 SCHs, and 1 SCH and 
RRC that will be reclassified as urban for the standardized amount in 
FY 2002 and, therefore, are not included in these rows.
    The next two groupings are based on type of ownership and the 
hospital's Medicare utilization expressed as a percent of total patient 
days. These data are taken primarily from the FY 1999 Medicare cost 
report files, if available (otherwise FY 1998 data are used). Data 
needed to determine ownership status or Medicare utilization 
percentages were unavailable for 52 and 78 hospitals, respectively. For 
the most part, these appear to be new hospitals, without cost reports 
on file for FY 1999.
    The next series of groupings concern the geographic 
reclassification status of hospitals. The first grouping displays all 
hospitals that were reclassified by the MGCRB for FY 2002. The next two 
groupings separate the hospitals in the first group by urban and rural 
status. The final row in Table I contains hospitals located in rural 
counties but deemed to be urban under section 1886(d)(8)(B) of the Act.

                                  Table I.--Impact Analysis of Changes For FY 2002 Operating Prospective Payment System
                                                         [Percent changes in payments per case]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                   Reclassi-
                                                                                       New      Include                  MCGRB      fication    All  FY
                                                    Num. of    DRG  re-  New  wage   overhead   contract   DRG &  WI   reclassi-      hold-      2002
                                                     hosps.   calib.\2\   data \3\  alloc.\4\  labor \5\    changes     fication    harmless    changes
                                                      \1\                                                     \6\         \7\        policy       \9\
                                                         (0)        (1)        (2)        (3)        (4)         (5)         (6)         (7)         (8)
--------------------------------------------------------------------------------------------------------------------------------------------------------
              By Geographic Location
 
All hospitals....................................      4,795        0.3        0.2       -0.1       -0.1         0.0        -0.2         0.2         2.1
  Urban hospitals................................      2,704        0.3        0.2       -0.1       -0.1         0.0        -0.7         0.2         1.9
    Large urban areas(populations over 1 million)      1,561        0.4        0.0       -0.1       -0.1        -0.1        -0.8         0.3         1.8
    Other urban areas (populations of 1 million        1,143        0.2        0.5       -0.2       -0.1         0.2        -0.5         0.1         2.0
     or fewer)...................................
    Rural hospitals..............................      2,091        0.0        0.0        0.2        0.2        -0.2         2.6         0.0         3.4
Bed Size (Urban):
    0-99 beds....................................        695       -0.1        0.1        0.1        0.1         0.0        -0.8         0.2         2.6
    100-199 beds.................................        948        0.3       -0.1        0.2        0.2         0.0        -0.7         0.3         2.1
    200-299 beds.................................        529        0.3        0.2        0.0        0.0         0.1        -0.7         0.3         2.0
    300-499 beds.................................        383        0.3        0.4       -0.3       -0.2         0.0        -0.7         0.2         1.8
    500 or more beds.............................        149        0.5        0.4       -0.4       -0.4         0.0        -0.6         0.1         1.6
Bed Size (Rural):
    0-49 beds....................................      1,226       -0.2        0.1        0.2        0.1        -0.3         0.3         0.0         3.4
    50-99 beds...................................        520       -0.1        0.0        0.2        0.1        -0.3         1.0         0.0         3.5
    100-149 beds.................................        203        0.0        0.0        0.3        0.2        -0.1         3.3         0.1         3.4
    150-199 beds.................................         75        0.1       -0.2        0.2        0.2        -0.2         5.2         0.0         3.6
    200 or more beds.............................         67        0.1       -0.1        0.1        0.1        -0.2         4.8         0.0         3.3
  Urban by Region:
    New England..................................        138        0.3        1.6       -0.3       -0.2         1.2        -0.3         0.2         3.0
    Middle Atlantic..............................        416        0.4       -0.5        0.0        0.1        -0.4        -0.7         0.6         1.3
    South Atlantic...............................        393        0.4        0.5       -0.1       -0.1         0.4        -0.8         0.3         2.4
    East North Central...........................        459        0.2        0.1       -0.2       -0.2        -0.3        -0.5         0.1         1.7
    East South Central...........................        160        0.3        1.0       -0.1       -0.1         0.8        -0.7         0.0         3.0
    West North Central...........................        187        0.2        0.4       -0.3       -0.3        -0.1        -0.7         0.0         1.7
    West South Central...........................        340        0.3       -0.2       -0.2       -0.1        -0.4        -0.7         0.0         1.3
    Mountain.....................................        136        0.2        0.8       -0.3       -0.3         0.3        -0.7         0.0         2.2
    Pacific......................................        429        0.5        0.0        0.1        0.1         0.1        -0.8         0.3         1.9

[[Page 40088]]

 
    Puerto Rico..................................         46        0.1        2.1       -0.8       -0.9         1.1        -0.8         0.2         3.3
  Rural by Region:
    New England..................................         50        0.0        0.0        0.1        0.1        -0.3         2.9         0.0         3.7
    Middle Atlantic..............................         75        0.1        0.1        0.1        0.1        -0.1         2.3         0.0         3.2
    South Atlantic...............................        269        0.1       -0.1        0.2        0.2        -0.2         2.9         0.0         3.6
    East North Central...........................        276       -0.2        0.0        0.1        0.2        -0.4         2.2         0.0         2.9
    East South Central...........................        263        0.0       -0.1        0.2        0.2        -0.2         3.2         0.0         3.7
    West North Central...........................        481       -0.3        0.3        0.2        0.1        -0.1         1.8         0.0         2.6
    West South Central...........................        333        0.0        0.3        0.2        0.2         0.1         3.6         0.0         4.8
    Mountain.....................................        195        0.0       -0.1        0.2        0.1        -0.3         1.7         0.0         3.0
    Pacific......................................        144        0.1       -0.9        0.2        0.2        -0.9         2.3         0.0         2.8
    Puerto Rico..................................          5       -0.3        6.1        0.2        0.1         5.6        -0.7         0.2         9.9
  By Payment Classification:
    Urban hospitals..............................      2,746        0.3        0.2       -0.1       -0.1         0.0        -0.6         0.2         1.9
    Large urban hospitals (populations over 1          1,632        0.4        0.0       -0.1       -0.1        -0.1        -0.7         0.3         1.9
     million)....................................
    Other urban hospitals (populations of 1            1,114        0.2        0.5       -0.2       -0.1         0.2        -0.5         0.1         2.0
     million or fewer)...........................
    Rural hospitals..............................      2,049        0.0        0.0        0.2        0.2        -0.2         2.4         0.0         3.4
  Teaching Status:...............................
    Non-teaching.................................      3,668        0.1        0.0        0.2        0.2         0.0         0.2         0.2         2.4
    Fewer than 100 Residents.....................        890        0.2        0.4       -0.2       -0.1         0.1        -0.6         0.2         2.0
    100 or more Residents........................        237        0.6        0.3       -0.5       -0.4         0.0        -0.5         0.1         1.7
Urban DSH:
  Non DSH........................................      1,879        0.1        0.2       -0.1       -0.1        -0.1        -0.1         0.2         1.9
  100 or more beds...............................      1,379        0.4        0.2       -0.1       -0.1         0.1        -0.7         0.2         1.9
  Less than 100 beds.............................        316        0.1       -0.1        0.3        0.3         0.0        -0.7         0.2         4.0
Rural DSH:
    Sole Community (SCH).........................        545        0.0        0.0        0.1        0.1        -0.3         0.3         0.0         3.1
    Referral Center (RRC)........................        152        0.2       -0.1        0.2        0.2        -0.1         5.2         0.0         3.8
Other Rural:
    100 or more beds.............................         70        0.0        0.1        0.3        0.3         0.1         1.5         0.1         3.7
    Less than 100 beds...........................        454       -0.1       -0.1        0.2        0.2        -0.4         0.6         0.0         4.5
Urban teaching and DSH:
    Both teaching and DSH........................        758        0.5        0.3       -0.3       -0.2         0.1        -0.7         0.2         1.9
    Teaching and no DSH..........................        298        0.2        0.4       -0.3       -0.3        -0.1        -0.5         0.3         1.8
    No teaching and DSH..........................        937        0.3        0.0        0.2        0.2         0.1        -0.6         0.2         2.2
    No teaching and no DSH.......................        753        0.1       -0.1        0.1        0.1        -0.1        -0.6         0.2         1.8
Rural Hospital Types:
  Non-special status.............................        805       -0.2        0.0        0.3        0.2        -0.2         0.9         0.0         3.8
  RRC............................................        165        0.1       -0.1        0.2        0.2        -0.1         6.3         0.1         3.7
  SCH............................................        680        0.0        0.0        0.1        0.1        -0.3         0.3         0.0         2.7
  Medicare-dependent hospitals (MDH).............        329       -0.2        0.2        0.1        0.1        -0.2         0.4         0.0         3.6
  SCH and RRC....................................         70        0.0        0.0        0.1        0.1        -0.3         2.1         0.0         2.9
Type of Ownership:
  Voluntary......................................      2,765        0.3        0.1       -0.1       -0.1        -0.1        -0.3         0.2         2.0
  Proprietary....................................        717        0.3        0.1        0.0        0.0         0.1         0.0         0.1         2.4
  Government.....................................      1,261        0.3        0.4       -0.1        0.0         0.3         0.0         0.0         0.0
  Unknown........................................         52       -0.4        0.6        0.1        0.1        -0.1        -1.8         1.0         1.6
Medicare Utilization as a Percent of Inpatient
 Days:
  0-25...........................................        396        0.7        0.2        0.0        0.0         0.5        -0.4         0.2         2.5
  25-50..........................................      1,886        0.4        0.2       -0.2       -0.2         0.0        -0.6         0.2         1.9
  50-65..........................................      1,843        0.1        0.2        0.0        0.0         0.0         0.1         0.2         2.4
  Over 65........................................        592        0.1       -0.2        0.2        0.2        -0.1         0.3         0.2         2.2
  Unknown........................................         78        0.3       -0.3       -0.1        0.0        -0.6         0.8         0.2         0.7
Hospitals Reclassified by the Medicare Geographic
       Classification Review Board: FY 2002
                Reclassifications:
 
All Reclassified Hospitals.......................        628        0.2        0.2        0.0        0.0         0.0         5.0         0.1         3.3
  Standardized Amount Only.......................         74        0.1       -0.4        0.3        0.4        -0.3         2.2         0.4         3.8
  Wage Index Only................................        391        0.2        0.0        0.0        0.0        -0.1         5.5         0.1         2.8
  Both...........................................         58        0.2        0.3        0.1        0.1         0.1         5.1         0.0         0.6
  All Nonreclassified Hospitals..................      4,246        0.3        0.2       -0.1        0.1         0.0         0.8         0.2         2.1
All Reclassified UrbanHospitals..................        117        0.4        0.7       -0.3       -0.3         0.2         4.2         0.1         2.6
  Standardized Amount Only.......................         14        0.2       -0.3        0.5        0.5        -0.1         0.4         0.3         2.6
  Wage Index Only................................         83        0.4        0.7       -0.5       -0.4         0.2         4.5         0.1         2.4
  Both...........................................         20        0.2        0.7        0.2        0.3         0.8         4.7         0.5         3.5
  Urban Nonreclassified Hospitals................      2,549        0.3        0.2       -0.1       -0.1         0.0        -1.0         0.2         1.8
Reclassified Rural Hospitals.....................        511        0.1        0.0        0.2        0.2        -0.2         5.5         0.0         3.7
  Standardized Amount Only.......................         16        0.0       -0.1        0.2        0.2        -0.3         3.8         0.0         2.3
  Wage Index Only................................        472        0.1        0.0        0.2        0.2        -0.2         5.3         0.0         3.7
  Both...........................................         23        0.0        0.2        0.1        0.1        -0.1         9.3         0.0         4.0
  Rural Nonreclassified Hospitals................      1,577       -0.1        0.0        0.2        0.1        -0.3        -0.6         0.0         3.0

[[Page 40089]]

 
Other Reclassified Hospitals (Section                     41        0.1        0.6        0.1        0.1         0.4         0.8        -0.7         4.2
 1886(D)(8)(B))..................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the
  national total. Discharge data are from FY 2000, and hospital cost report data are from reporting periods beginning in FY 1999 and FY 1998.
\2\ This column displays the payment impact of the recalibration of the DRG weights based on FY 2000 MedPAR data and the DRG reclassification changes,
  in accordance with section 1886(d)(4)(C) of the Act.
\3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1998 cost reports.
\4\ This column displays the impact of removing the salaries and hours of lower-wage, overhead employees and the overhead wage-related costs associated
  with the excluded areas of the hospital from the wage index calculation.
\5\ This column displays the impact of including contract pharmacy and contract laboratory costs and hours in the wage index calculation.
\6\ This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to calculate
  the wage index, the revised overhead allocation, the laboratory and pharmacy contract labor costs, and the budget neutrality adjustment factor for
  these two changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act. Thus, it represents the combined impacts shown in
  columns 1, 2, 3, and 4, and the FY 2002 budget neutrality factor of .995821.
\7\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate
  the FY 2002 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2002. Reclassification for
  prior years has no bearing on the payment impacts shown here.
\8\ Shown here are the effects of our policy to hold-harmless other hospitals in an urban area where certain hospitals are reclassified elsewhere by
  including the wage data of reclassified hospitals in their geographic area as well as the area to which they are reclassified.
\9\ This column shows changes in payments from FY 2001 to FY 2002. It incorporates all of the changes displayed in columns 5, 6, and 7 (the changes
  displayed in columns 1, 2, 3, and 4 are included in column 5). It also displays the impact of the FY 2002 update, changes in hospitals'
  reclassification status in FY 2002 compared to FY 2001, and the difference in outlier payments from FY 2001 to FY 2002. It also reflects section 213
  of Public law 106-554, which permitted all SCHs to rebase for a 1996 hospital-specific rate. The sum of these columns may be different from the
  percentage changes shown here due to rounding and interactive effects.

B. Impact of the Final Changes to the DRG Reclassifications and 
Recalibration of Relative Weights (Column 1)

    In column 1 of Table I, we present the combined effects of the DRG 
reclassifications and recalibration, as discussed in section II. of the 
preamble to this final rule. Section 1886(d)(4)(C)(i) of the Act 
requires us to annually make appropriate classification changes and to 
recalibrate the DRG weights in order to reflect changes in treatment 
patterns, technology, and any other factors that may change the 
relative use of hospital resources.
    We compared aggregate payments using the FY 2001 DRG relative 
weights (GROUPER version 18) to aggregate payments using the final FY 
2002 DRG relative weights (GROUPER version 19). Overall payments 
increase 0.3 percent due to the DRG reclassification and recalibration. 
We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we 
have applied a budget neutrality factor to ensure that the overall 
payment impact of the DRG (and wage index) changes is budget neutral. 
This budget neutrality factor of 0.995821 is applied to payments in 
Column 5.
    We estimate that the DRG changes effective with this final rule 
would result in higher payments to urban hospitals (0.3 percent) and 
would have a 0 percent impact on payments to rural hospitals. The 
changes also would result in higher payments to larger hospitals than 
to smaller hospitals. This impact is consistent for both urban and 
rural bed size groups.
    This distributional impact likely results from the final changes to 
major diagnostic category (MDC) 5 ``Diseases and Disorders of the 
Circulatory System.'' As described in section II. of the preamble of 
this final rule, we are removing cardiac defibrillator cases from DRGs 
104 and 105, and creating two new DRGs for these cases. In addition, we 
are revising the basis of the DRG assignment for cases involving 
percutaneous transluminal coronary angioplasty based on whether the 
patient experienced an acute myocardial infarction. Because MDC 5 is a 
high volume category, refining the categorizations of these cases has a 
noticeable overall payment impact.

C. Impact of Updating the Wage Data and the Final Changes to the Wage 
Index Calculation (Columns 2, 3 & 4)

    Section 1886(d)(3)(E) of the Act requires that, beginning October 
1, 1993, we annually update the wage data used to calculate the wage 
index. In accordance with this requirement, the final wage index for FY 
2002 is based on data submitted for hospital cost reporting periods 
beginning on or after October 1, 1997 and before October 1, 1998. As 
with column 1, the impact of the new data on hospital payments is 
isolated in column 2 by holding the other payment parameters constant 
in the two simulations. That is, column 2 shows the percentage changes 
in payments when going from a model using the FY 2001 wage index (based 
on FY 1997 wage data before geographic reclassifications to a model 
using the FY 2002 prereclassification wage index based on FY 1998 wage 
data).
    The wage data collected on the FY 1998 cost reports are similar to 
the data used in the calculation of the FY 2001 wage index. For a 
thorough discussion of the data used to calculate the wage index, see 
section III.B. of the preamble of this final rule. The July 30, 1999 
final rule (64 FR 41505) indicated that we would phase-out costs 
related to GME and certified registered nurse anesthestists (CRNA) from 
the calculation of the wage index over a 5-year period, beginning in FY 
2000. The FY 2001 wage index was based on a blend of 60 percent of an 
average hourly wage including these costs, and 40 percent of an average 
hourly wage excluding these costs. For FY 2002, the wage index is based 
on a blend of 40 percent of an average hourly wage including these 
costs, and 60 percent of an average hourly wage excluding these costs. 
This change is reflected in column 2.
    The results indicate that the new wage data are estimated to 
provide a 0.2 percent increase for hospital payments overall (prior to 
applying the budget neutrality factor, see column 5). In some cases, 
the results shown in this final rule may be very different from the 
impacts shown in the proposed rule. This is due to the large number of 
data revisions submitted by hospitals after the proposed wage index was 
calculated. Approximately 30 percent of hospitals submitted revisions 
in the interim.
    Rural hospitals are generally estimated to experience a negligible

[[Page 40090]]

impact from the new wage data, although rural hospitals in Puerto Rico 
experience a 6.1 percent increase, likely due to the 13 percent 
increase in the value of five providers' FY 2002 wage index compared to 
the wage index for those same providers for FY 2001. Additionally, 
rural hospitals in West North Central and West South Central experience 
estimated wage index-driven increases of more than 0.3 percent. 
Meanwhile, hospitals in the Pacific census division experience a 0.9 
percent decrease.
    Urban hospitals as a group are estimated to benefit positively from 
the updated wage data. The other urban hospitals appear to experience a 
0.5 percent increase and estimated payments to urban hospitals overall 
showed an increase of 0.2 percent. Among urban census divisions, Puerto 
Rico experiences a 2.1 percent increase, the New England division 
experiences a 1.6 percent increase, East South Central experiences a 
1.0 percent increase, and Middle Atlantic a 0.5 percent decrease.
    Columns 3 and 4, respectively, show that the final change to the 
overhead calculation and the policy to include contract labor costs in 
the wage index discussed in detail in section III.C. of the preamble of 
this final rule both appear to benefit rural hospitals and small 
hospitals. Urban hospitals as a group are impacted by a 0.1 percent 
decrease to their payments from each change. Rural hospitals are 
expected to receive an estimated 0.2 percent increase in payments due 
to this policy change.
    The following chart compares the shifts in wage index values for 
labor market areas for FY 2001 relative to FY 2002. This chart 
demonstrates the impact of the final changes for the FY 2002 wage index 
relative to the FY 2001 wage index. The majority of labor market areas 
(335) experience less than a 5-percent change. A total of 28 labor 
market areas experience an increase of more than 5 percent, with 2 
having an increase greater than 10 percent. A total of 11 areas 
experience decreases of more than 5-percent. Of those, 1 declines by 
more than 10 percent.

------------------------------------------------------------------------
                                                       Number of labor
                                                        market areas
    Percentage change in area wage index values    ---------------------
                                                     FY 2001    FY 2002
------------------------------------------------------------------------
Increase more than 10 percent.....................          1          2
Increase more than 5 percent and less than 10              20         26
 percent..........................................
Increase or decrease less than 5 percent..........        339        335
Decrease more than 5 percent and less than 10              14         10
 percent..........................................
Decrease more than 10 percent.....................          1          1
------------------------------------------------------------------------

    Among urban hospitals, 129 would experience an increase of between 
5 and 10 percent, and 3 experience an increase of more than 10 percent. 
A total of 18 rural hospitals have increases greater than 5 percent, 
with 5 increasing greater than 10 percent. On the negative side, 29 
urban hospitals have decreases in their wage index values of at least 5 
percent but less than 10 percent. Four urban hospitals have decreases 
in their wage index values greater than 10 percent. There are no rural 
hospitals with decreases in their wage index values greater than 5 
percent. The following chart shows the projected impact for urban and 
rural hospitals.

------------------------------------------------------------------------
                                                     Number of hospitals
    Percentage change in area wage index values    ---------------------
                                                      Urban      Rural
------------------------------------------------------------------------
Increase more than 10 percent.....................          3          5
Increase more than 5 percent and less than 10             129         13
 percent..........................................
Increase or decrease less than 5 percent..........      2,531      2,166
Decrease more than 5 percent and less than 10              29          0
 percent..........................................
Decrease more than 10 percent.....................          4          0
------------------------------------------------------------------------

D. Combined Impact of DRG and Wage Index Changes-- Including Budget 
Neutrality Adjustment (Column 5)

    The impact of DRG reclassifications and recalibration on aggregate 
payments is required by section 1886(d)(4)(C)(iii) of the Act to be 
budget neutral. In addition, section 1886(d)(3)(E) of the Act specifies 
that any updates or adjustments to the wage index are to be budget 
neutral. As noted in the Addendum to this final rule, we compared 
simulated aggregate payments using the FY 2001 DRG relative weights and 
wage index to simulated aggregate payments using the final FY 2002 DRG 
relative weights and wage index. Based on this comparison, we computed 
a wage and recalibration budget neutrality factor of 0.995821. In Table 
I, the combined overall impacts of the effects of both the DRG 
reclassifications and recalibration and the updated wage index are 
shown in column 5. The 0.0 percent impact for all hospitals 
demonstrates that these changes, in combination with the budget 
neutrality factor, are budget neutral.
    For the most part, the changes in this column are the sum of the 
changes in columns 1, 2, 3 and 4, minus approximately 0.4 percent 
attributable to the budget neutrality factor. There may be some 
variation of plus or minus 0.1 percent due to rounding.

E. Impact of MGCRB Reclassifications (Columns 6 & 7)

    Our impact analysis to this point has assumed hospitals are paid on 
the basis of their actual geographic location (with the exception of 
ongoing policies that provide that certain hospitals receive payments 
on bases other than where they are geographically located, such as 
hospitals in rural counties that are deemed urban under section 
1886(d)(8)(B) of the Act). The changes in column 5 reflect the per case 
payment impact of moving from this baseline to a simulation 
incorporating the MGCRB decisions for FY 2002. As noted below, these 
decisions may affect hospitals' standardized amount and wage index area 
assignments. The changes in column 7 reflect the postreclassified wage 
index values resulting from including the wage data for a reclassified 
hospital in both the area to

[[Page 40091]]

which it is reclassified and the area where the hospital is physically 
located.
    By February 28 of each year, the MGCRB makes reclassification 
determinations that will be effective for the next fiscal year, which 
begins on October 1. The MGCRB may approve a hospital's 
reclassification request for the purpose of using the other area's 
standardized amount, wage index value, or both.
    The final FY 2002 wage index values incorporate all of the MGCRB's 
reclassification decisions for FY 2002. The wage index values also 
reflect any decisions made by the CMS Administrator through the appeals 
and review process for MGCRB decisions.
    The overall effect of geographic reclassification is required by 
section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we 
applied an adjustment of 0.990675 to ensure that the effects of 
reclassification are budget neutral. (See section II.A.4.b. of the 
Addendum to this final rule.) This results in a larger budget 
neutrality offset than the FY 2001 factor of 0.993187. This larger 
offset is accounted for by the extension of wage index 
reclassifications for 3 years as a result of section 304 of Public Law 
106-554, and our final policy to hold-harmless the calculation of urban 
areas' wage indexes for reclassifications out of the area (see column 
7). We have identified 162 hospitals that were reclassified for FY 
2001, but not FY 2002, that will nonetheless continue to be 
reclassified due to section 304 of Public Law 106-554.
    As a group, rural hospitals benefit from geographic 
reclassification. Their payments rise 2.6 percent in column 6. Payments 
to urban hospitals decline 0.7 percent. Hospitals in other urban areas 
see a decrease in payments of 0.5 percent, while large urban hospitals 
lose 0.8 percent. Among urban hospital groups (that is, bed size, 
census division, and special payment status), payments generally 
decline.
    A positive impact is evident among most of the rural hospital 
groups. The largest increases are in the West South Central, East South 
Central, New England and the South Atlantic regions. These regions 
receive increases of 3.6, 3.2, and 2.9 and 2.9, respectively. The rural 
census division for the Puerto Rico region appears to receive an 
estimated decrease in payments of 0.7 percent.
    Among all the hospitals that were reclassified for FY 2002, the 
MGCRB changes are estimated to provide a 5.0 percent increase in 
payments. Urban hospitals reclassified for FY 2002 are anticipated to 
receive an increase of 4.2 percent, while rural reclassified hospitals 
are expected to benefit from the MGCRB changes with a 5.5 percent 
increase in payments. Overall, among hospitals that were reclassified 
for purposes of the standardized amount only, a payment increase of 2.2 
percent is expected, while those reclassified for purposes of the wage 
index only show a 5.5 percent increase in payments. Payments to urban 
hospitals that did not reclassify are expected to decrease by 1.0 
percent due to the budget neutrality of MGCRB changes. Those hospitals 
located in rural counties but deemed to be urban under section 
1886(d)(8)(B) of the Act are expected to receive an increase in 
payments of 0.1 percent.
    Column 7 shows the impacts of our final policy to include the wage 
data for a reclassified hospital in both the area to which it is 
reclassified and the area where the hospital is physically located. 
This change affects overall payments by 0.2 percent, partially 
accounting for the larger budget neutrality factor compared to FY 2001. 
The payment impacts are generally largest in urban hospital groups, 
with the largest impact, 0.6 percent, experienced by urban hospitals in 
the Middle Atlantic census division.

F. All Changes (Column 8)

    Column 8 compares our estimate of payments per case, incorporating 
all changes reflected in this final rule for FY 2002 (including 
statutory changes), to our estimate of payments per case in FY 2001. It 
includes the effects of the 2.75 percent update to the standardized 
amounts and the hospital-specific rates for MDHs and SCHs. It also 
reflects the 1.1 percentage point difference between the projected 
percentage of outlier payments in FY 2001 (5.1 percent of total DRG 
payments) and the current estimate of the percentage of actual outlier 
payments in FY 2001 (6.2 percent), as described in the introduction to 
this Appendix and the Addendum to this final rule.
    We also note that section 211 of Public Law 106-554 changed the 
criteria for hospitals to qualify for DSH payment status. Since more 
hospitals are now eligible to receive DSH payments for the full FY 
2002, as opposed to for just the second 6 months of FY 2001, DSH 
payments to providers in FY 2002 would increase and this change is also 
captured in column 8.
    Section 213 of Public Law 106-554 provided that all SCHs may elect 
to receive payment on the basis of their costs per case during their 
cost reporting period that began during 1996. For FY 2002, eligible 
SCHs that rebase receive a hospital-specific rate comprised of 50 
percent of the higher of their FY 1982 or FY 1987 hospital-specific 
rate or their Federal rate, and 50 percent of their 1996 hospital-
specific rate. The impact of this provision is modeled in column 8 as 
well.
    There might also be interactive effects among the various factors 
comprising the payment system that we are not able to isolate. For 
these reasons, the values in column 8 may not equal the sum of the 
changes in columns 5, 6, and 7, plus the other impacts that we are able 
to identify.
    Hospitals in urban areas experience a 1.9 percent increase in 
payments per case compared to FY 2001. The net 0.5 percent negative 
impact due to reclassification (columns 6 and 7) is offset by a similar 
negative impact for FY 2001 of 0.4 percent (65 FR 47196). Hospitals in 
rural areas, meanwhile, experience a 3.4 percent payment increase. This 
is primarily due to the change in the DSH threshold to 15 percent for 
all hospitals enacted by section 211 of Public Law 106-554 effective 
for discharges on or after April 1, 2001, and the positive effect of 
the reclassification changes (2.6 percent increase).
    The impact of lowering the DSH threshold is demonstrated in Column 
8, although we would note that the estimated FY 2001 payments do 
reflect 6 months of payments to hospitals affected by this change. The 
impacts are seen in the rows displaying urban hospitals with fewer than 
100 beds receiving DSH (4.0 percent increase), and all rural DSH 
categories.
    Among urban census divisions, payments increased between 1.3 and 
3.3 percent between FY 2001 and FY 2002. The rural census division 
experiencing the smallest increase in payments was the West North 
Central region (2.6 percent). The largest increases by rural hospitals 
is in Puerto Rico, where payments appear to increase by 9.9 percent, 
and West South Central, where payments appear to increase by 4.8 
percent. All 5 of the rural Puerto Rico hospitals experienced an 
increase of greater than 10 percent in their wage index values 
(comparison of FY 2001 and FY 2002). Rural New England, East South 
Central, and South Atlantic regions also benefited with 3.7, 3.7, and 
3.6 percent respectively.
    Among special categories of rural hospitals, those hospitals 
receiving payment under the hospital-specific methodology (SCHs, MDHs, 
and SCH/RRCs) experience payment increases of 2.7 percent, 3.6 percent, 
and 2.9 percent, respectively. This outcome is primarily related to the 
fact that hospitals receiving payments under the hospital-specific 
methodology are not eligible for outlier payments. Therefore,

[[Page 40092]]

these hospitals do not experience negative payment impacts from the 
decline in outlier payments from FY 2001 to FY 2002 (from 6.2 percent 
of total DRG plus outlier payments to 5.1 percent) as do hospitals paid 
based on the national standardized amounts.
    Among hospitals that were reclassified for FY 2002, hospitals 
overall are estimated to receive a 3.3 percent increase in payments. 
Urban hospitals reclassified for FY 2002 are anticipated to receive an 
increase of 2.6 percent, while rural reclassified hospitals are 
expected to benefit from reclassification with a 3.7 percent increase 
in payments. Overall, among hospitals reclassified for purposes of the 
standardized amount only, a payment increase of 3.8 percent is 
expected, while those hospitals reclassified for purposes of the wage 
index only show an expected 2.8 percent increase in payments. Those 
hospitals located in rural counties but deemed to be urban under 
section 1886(d)(8)(B) of the Act are expected to receive an increase in 
payments of 4.2 percent.

             Table II.--Impact Analysis of Changes For FY 2002 Operating Prospective Payment System
                                               [Payments per case]
----------------------------------------------------------------------------------------------------------------
                                                                           Average  FY  Average  FY
                                                                Num. of        2001         2002       All  FY
                                                                 hosp.       payment      payment        2002
                                                                           per case\1\  per case\1\    changes
                                                                      (1)          (2)          (3)          (4)
----------------------------------------------------------------------------------------------------------------
                   By Geographic Location                           4,795        6,994        7,141          2.1
All hospitals...............................................
  Urban hospitals...........................................        2,704        7,559        7,703          1.9
  Large urban areas (populations over 1 million)............  ...........
    Other urban areas (populations of 1 million of fewer)...        1,143        6,853        6,989          2.0
    Rural hospitals.........................................        2,091        4,808        4,972          3.4
Bed Size (Urban)............................................          695        5,110        5,246          2.6
  0-99 beds.................................................  ...........  ...........  ...........  ...........
  100-199 beds..............................................          948        6,313        6,444          2.1
  200-299 beds..............................................          529        7,218        7,364          2.0
  300-499 beds..............................................          383        8,139        8,283          1.8
  500 or more beds..........................................          149        9,875       10,035          1.6
Bed Size (Rural)............................................        1,226        3,984        4,118          3.4
  0-49 beds.................................................  ...........  ...........  ...........  ...........
  50-99 beds................................................          520        4,526        4,683          3.5
  100-149 beds..............................................          203        4,858        5,022          3.4
  150-199 beds..............................................           75        5,336        5,529          3.6
  200 or more beds..........................................           67        6,188        6,392          3.3
Urban by Region.............................................          138        8,014        8,254          3.0
  New England...............................................
  Middle Atlantic...........................................          416        8,600        8,713          1.3
  South Atlantic............................................          393        7,169        7,338          2.4
  East North Central........................................          459        7,215        7,335          1.7
  East South Central........................................          160        6,776        6,976          3.0
  West North Central........................................          187        7,342        7,470          1.7
  West South Central........................................          340        6,998        7,090          1.3
  Mountain..................................................          136        7,308        7,467          2.2
  Pacific...................................................          429        8,939        9,109          1.9
  Puerto Rico...............................................           46        3,207        3,312          3.3
Rural by Region.............................................           50        5,740        5,950          3.7
  New England...............................................  ...........  ...........  ...........  ...........
  Middle Atlantic...........................................           75        5,114        5,277          3.2
  South Atlantic............................................          269        4,950       51,128          3.6
  East North Central........................................          276        4,813        4,951          2.9
  East South Central........................................          263        4,423        4,587          3.7
  West North Central........................................          481        4,714        4,839          2.6
  West South Central........................................          333        4,249        4,452          4.8
  Mountain..................................................          195        5,168        5,321          3.0
  Pacific...................................................          144        6,090        6,263          2.8
  Puerto Rico...............................................            5        2,521        2,771          9.9
By Payment Classification: Urban hospitals..................        2,746        7,538        7,682          1.9
Large urban hospitals (populations over 1 million)..........        1,632        8,026        8,175          1.9
Other urban hospitals (populations of 1 million or fewer)...        1,114        6,870        7,006          2.0
Rural hospitals.............................................        2,049        4,791        4,954          3.4
Teaching Status.............................................        3,668        5,638        5,775          2.4
  Non-teaching..............................................  ...........  ...........  ...........  ...........
  Fewer than 100 Residents..................................          890        7,327        7,473          2.0
  100 or more Residents.....................................          237       11,280       11,473          1.7
Urban DSH...................................................        1,879        6,356        6,479          1.9
  Non DSH...................................................  ...........  ...........  ...........  ...........
  100 or more beds..........................................        1,379        8,152        8,307          1.9
  Less than 100 beds........................................          316        4,973        5,173          4.0
Rural DSH...................................................          545        4,650        4,796          3.1
  Sole Community (SCH)......................................  ...........  ...........  ...........  ...........
  Referral Center (RRC).....................................          152        5,542        5,754          3.8

[[Page 40093]]

 
Other Rural.................................................           70        4,320        4,479          3.7
  100 or more beds..........................................  ...........  ...........  ...........  ...........
  Less than 100 beds........................................          454        3,937        4,115          4.5
Urban teaching and DSH:                                       ...........  ...........  ...........  ...........
  Both teaching and DSH.....................................          758        9,081        9,250          1.9
  Teaching and no DSH.......................................          298        7,577        7,715          1.8
  No teaching and DSH.......................................          937        6,343        6,481          2.2
  No teaching and no DSH....................................          753        5,895        6,002          1.8
Rural Hospital Types                                          ...........  ...........  ...........  ...........
  Non-special status........................................          805        4,048        4,204          3.8
  RRC.......................................................          165        5,433        5,636          3.7
  SCH.......................................................          680        4,884        5,017          2.7
  Medicare-dependent hospitals (MDH)........................          329        3,852        3,991          3.6
  SCH and RRC...............................................           70        5,902        6,073          2.9
Type of Ownership: Voluntary................................        2,341        7,149        7,295          2.1
  Proprietary...............................................          645        6,641        6,773          2.0
  Government................................................          962        6,259        6,437          2.8
  Unknown...................................................          847        7,151        7,293          2.0
Medicare Utilization as a Percent of Inpatient Days:
  0-25......................................................          396        9,564        9,807          2.5
  25-50.....................................................        1,886        8,045        8,195          1.9
  50-65.....................................................        1,843        6,040        6,184          2.4
  Over 65...................................................          592        5,422        5,543          2.2
  Unknown...................................................           78       10,360       10,433          0.7
 
      Hospitals Reclassified by the Medicare Geographic
   Classification Review Board: FY 2002 Reclassifications:
 
All Reclassified Hospitals..................................          628        6,234        6,438          3.3
  Standardized Amount Only..................................           74        5,210        5,409          3.8
  Wage Index Only...........................................          391        6,103        6,270          2.8
  Both......................................................           58        6,876        6,919          0.6
  All Nonreclassified Hospitals.............................        4,246        7,122        7,269          2.1
All Reclassified Urban Hospitals............................          117        8,365        8,578          2.6
  Standardized Amount Only..................................           14        5,990        6,143          2.6
  Wage Index Only...........................................           83        9,072        9,294          2.4
  Both......................................................           20        6,064        6,276          3.5
  Urban Nonreclassified Hospitals...........................        2,549        7,539        7,678          1.8
All Reclassified Rural Hospitals............................          511        5,383        5,584          3.7
  Standardized Amount Only..................................           16        5,183        5,302          2.3
  Wage Index Only...........................................          472        5,387        5,589          3.7
  Both......................................................           23        5,381        5,597          4.0
  Rural Nonreclassified Hospitals...........................        1,577        4,271        4,399          3.0
Other Reclassified Hospitals (Section 1886(D)(8)(B))........           41        4,838        5,043          4.2
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.

    Table II presents the projected impact of the final changes for FY 
2002 for urban and rural hospitals and for the different categories of 
hospitals shown in Table I. It compares the estimated payments per case 
for FY 2001 with the average estimated per case payments for FY 2002, 
as calculated under our models. Thus, this table presents, in terms of 
the average dollar amounts paid per discharge, the combined effects of 
the changes presented in Table I. The percentage changes shown in the 
last column of Table II equal the percentage changes in average 
payments from column 8 of Table I.

IX. Impact for Critical Access Hospitals (CAHs)

    There are approximately 365 facilities that qualify as CAHs. These 
CAHs are paid based on reasonable costs for their services to 
inpatients and outpatients. We examined several parts of the final 
rule, as discussed in detail in section VI.B. of the preamble, for 
their potential impact on CAHs.

A. Exclusion of CAHs From Payment Window Requirements

    In this final rule, we are clarifying the policy that CAHs are not 
subject to the payment window provisions of section 1886(a)(3) of the 
Act. Existing regulations do not require application of these 
provisions to CAHs, and we are not aware of specific situations in 
which they are now being applied. Consequently, we do not expect any 
increase or decrease in Medicare spending based on this clarification.

B. Availability of CRNA Pass-Through for CAHs

    Under existing Sec. 412.113(c), CRNA pass-through payment is 
available only to hospitals that either qualified for the pass-through 
of costs of anesthesia services furnished in calendar year 1989, or met 
certain conditions, including having employed or contracted with a 
qualified nonphysician anesthetist as of January

[[Page 40094]]

1, 1988, to perform anesthesia services. In this final rule, we are 
specifying that certain CAHs that meet the pass-through criteria would 
qualify for pass-through payments. Under the existing criterion, we 
believe the only facilities that could qualify for the pass-through as 
CAHs are those that would have qualified for the pass-through if they 
had elected to continue participating in Medicare as hospitals rather 
than converting to CAH status. We do not expect any increase or 
decrease in Medicare spending based on the final change in the 
regulations.

C. Payment for Emergency Room On-Call Physicians

    In accordance with the amendments made by section 204 of Public Law 
106-544, in this final rule, we are specifying that we will recognize 
as allowable costs, amounts for reasonable compensation and related 
costs for emergency room physicians who are on call but who are not 
present on the premises of a CAH. We expect that at least some CAHs 
will elect to compensate emergency room physicians for being on call 
and that, as a result, Medicare spending for CAH services will 
increase. However, we do not have information to develop a reliable 
estimate of how many CAHs will make this election, or how much 
physician compensation costs they will incur for on call time.

D. Treatment of Ambulance Services Furnished by Certain CAHs

    In accordance with the provisions of section 205 of Public Law 106-
554, we are amending the existing CAH regulations to provide for 
payment to CAHs for the reasonable costs of ambulance services 
furnished by a CAH or an entity owned or operated by the CAH if certain 
statutory requirements are met. We expect that at least some CAHs or 
entities owned or operated by CAHs will be able to qualify for payment 
for their ambulance services. To the extent that CAHs or CAH owned or 
operated entities furnish these services under the conditions specified 
in the law, ambulance services will be paid for at higher rates than 
would otherwise apply. As a result, Medicare spending for ambulance 
services will increase. However, we do not have sufficient information 
or data to develop a reliable estimate of how many CAHs or entities 
will qualify or the dollar amount of ambulance service costs they will 
incur.

E. Qualified Practitioners for Preanesthesia and Postanesthesia 
Evaluations in CAHs

    As discussed in section VI.B. of this final rule, in an effort to 
eliminate or minimize potential issues relating to beneficiary access 
to medical services in rural areas, we are allowing CRNAs who 
administer the anesthesia to conduct the preanesthesia and 
postanesthesia evaluations in a CAH. As with any licensed independent 
health care provider, the final change will not permit CRNAs to 
practice beyond his or her licensed scope of practice.
    We believe that this policy will increase flexibility of providers 
in furnishing medical services in rural areas. However, we do not have 
information or data to develop a reliable estimate of how many CRNAs 
would be used to conduct preanesthesia and postanesthesia evaluations 
in CAHs or what the associated costs would be.

X. Impact of Changes in the Capital Prospective Payment System

A. General Considerations

    We now have cost report data for the 8th year of the capital 
prospective payment system (cost reports beginning in FY 1999) 
available through the March 2001 update of the HCRIS. We also have 
updated information on the projected aggregate amount of obligated 
capital approved by the fiscal intermediaries. However, our impact 
analysis of payment changes for capital-related costs is still limited 
by the lack of hospital-specific data on several items. These are the 
hospital's projected new capital costs for each year, its projected old 
capital costs for each year, and the actual amounts of obligated 
capital that will be put in use for patient care and recognized as 
Medicare old capital costs in each year. The lack of this information 
affects our impact analysis in the following ways:
     Major investment in hospital capital assets (for example, 
in building and major fixed equipment) occurs at irregular intervals. 
As a result, there can be significant variation in the growth rates of 
Medicare capital-related costs per case among hospitals. We do not have 
the necessary hospital-specific budget data to project the hospital 
capital growth rate for individual hospitals.
     Our policy of recognizing certain obligated capital as old 
capital makes it difficult to project future capital-related costs for 
individual hospitals. Under Sec. 412.302(c), a hospital is required to 
notify its intermediary that it has obligated capital by the later of 
October 1, 1992, or 90 days after the beginning of the hospital's first 
cost reporting period under the capital prospective payment system. The 
intermediary must then notify the hospital of its determination whether 
the criteria for recognition of obligated capital have been met by the 
later of the end of the hospital's first cost reporting period subject 
to the capital prospective payment system or 9 months after the receipt 
of the hospital's notification. The amount that is recognized as old 
capital is limited to the lesser of the actual allowable costs when the 
asset is put in use for patient care or the estimated costs of the 
capital expenditure at the time it was obligated. We have substantial 
information regarding fiscal intermediary determinations of projected 
aggregate obligated capital amounts. However, we still do not know when 
these projects will actually be put into use for patient care, the 
actual amount that will be recognized as obligated capital when the 
project is put into use, or the Medicare share of the recognized costs. 
Therefore, we do not know actual obligated capital commitments for 
purposes of the FY 2002 capital cost projections. In Appendix B of this 
final rule, we discuss the assumptions and computations that we employ 
to generate the amount of obligated capital commitments for use in the 
FY 2002 capital cost projections.
    In Table III of this section, we present the redistributive effects 
that are expected to occur between ``hold-harmless'' hospitals and 
``fully prospective'' hospitals in FY 2002. In addition, we have 
integrated sufficient hospital-specific information into our actuarial 
model to project the impact of the FY 2002 capital payment policies by 
the standard prospective payment system hospital groupings. While we 
now have actual information on the effects of the transition payment 
methodology and interim payments under the capital prospective payment 
system and cost report data for most hospitals, we still need to 
randomly generate numbers for the change in old capital costs, new 
capital costs for each year, and obligated amounts that will be put in 
use for patient care services and recognized as old capital each year. 
We continue to be unable to predict accurately FY 2002 capital costs 
for individual hospitals, but with the most recent data on hospitals' 
experience under the capital prospective payment system, there is 
adequate information to estimate the aggregate impact on most hospital 
groupings.

[[Page 40095]]

B. Projected Impact Based on the FY 2002 Actuarial Model

1. Assumptions
    In this impact analysis, we model dynamically the impact of the 
capital prospective payment system from FY 2001 to FY 2002 using a 
capital cost model. The FY 2002 model, as described in Appendix B of 
this final rule, integrates actual data from individual hospitals with 
randomly generated capital cost amounts. We have capital cost data from 
cost reports beginning in FY 1989 through FY 1999 as reported on the 
March 2001 update of HCRIS, interim payment data for hospitals already 
receiving capital prospective payments through PRICER, and data 
reported by the intermediaries that include the hospital-specific rate 
determinations that have been made through April 1, 2001 in the 
provider-specific file. We used these data to determine the FY 2002 
capital rates. However, we do not have individual hospital data on old 
capital changes, new capital formation, and actual obligated capital 
costs. We have data on costs for capital in use in FY 1999, and we age 
that capital by a formula described in Appendix B. Therefore, we need 
to randomly generate only new capital acquisitions for any year after 
FY 1999. All Federal rate payment parameters are assigned to the 
applicable hospital. We will continue to pay regular exceptions during 
cost reporting periods beginning before October 1, 2001 but ending in 
FY 2002. However, in FY 2003 and later, payments will no longer be made 
under the regular exceptions provision; hence, we will no longer 
require the actuarial model described in Appendix B of this final rule.
    For purposes of this impact analysis, the FY 2002 actuarial model 
includes the following assumptions:
     Medicare inpatient capital costs per discharge will change 
at the following rates during these periods:

        Average Percentage Change in Capital Costs Per Discharge
------------------------------------------------------------------------
                                                              Percentage
                        Fiscal year                             change
------------------------------------------------------------------------
2000.......................................................         1.39
2001.......................................................         1.37
2002.......................................................         2.58
------------------------------------------------------------------------

     We estimate that the Medicare case-mix index will decrease 
by 0.9 percent in FY 2001 and will increase by 1.0 percent in FY 2002.
     The Federal capital rate and the hospital-specific rate 
were updated beginning in FY 1996 by an analytical framework that 
considers changes in the prices associated with capital-related costs 
and adjustments to account for forecast error, changes in the case-mix 
index, allowable changes in intensity, and other factors. The FY 2002 
update is 1.3 percent (see section IV. of the Addendum to this final 
rule).
2. Results
    We have used the actuarial model to estimate the change in payment 
for capital-related costs from FY 2001 to FY 2002. Table III shows the 
effect of the capital prospective payment system on low capital cost 
hospitals and high capital cost hospitals. We consider a hospital to be 
a low capital cost hospital if, based on a comparison of its initial 
hospital-specific rate and the applicable Federal rate, it will be paid 
under the fully prospective payment methodology. A high capital cost 
hospital is a hospital that, based on its initial hospital-specific 
rate and the applicable Federal rate, will be paid under the hold-
harmless payment methodology. We are no longer displaying a column for 
the hospital-specific payments in Table III since, beginning with FY 
2001, the transition blend percentage for fully prospective hospitals 
is 100 percent of the Federal rate and zero percent of the hospital-
specific rate, and all hospitals (except ``new'' hospitals under 
Sec. 412.324(b)) are paid based on 100 percent of the Federal rate for 
FY 2002. Based on our actuarial model, the breakdown of hospitals is as 
follows:

                               Capital Transition Payment Methodology for FY 2002
----------------------------------------------------------------------------------------------------------------
                                                                                         Percent of   Percent of
                      Type of hospital                         Percent of   Percent of    capital      capital
                                                               hospitals    discharges     costs       payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital...........................................           66           62           57           61
High Cost Hospital..........................................           34           38           43           39
----------------------------------------------------------------------------------------------------------------

    A low capital cost hospital may request to have its hospital-
specific rate redetermined based on old capital costs in the current 
year, through the later of the hospital's cost reporting period 
beginning in FY 1994 or the first cost reporting period beginning after 
obligated capital comes into use (within the limits established in 
Sec. 412.302(c) for putting obligated capital into use for patient 
care). If the redetermined hospital-specific rate is greater than the 
adjusted Federal rate, these hospitals will be paid under the hold-
harmless payment methodology. Regardless of whether the hospital became 
a hold-harmless payment hospital as a result of a redetermination, we 
continue to show these hospitals as low capital cost hospitals in Table 
III.
    Assuming no behavioral changes in capital expenditures, Table III 
displays the percentage change in payments from FY 2001 to FY 2002 
using the above described actuarial model. With the Federal rate, we 
estimate aggregate Medicare capital payments will increase by 4.27 
percent in FY 2002. This increase is noticeably somewhat lower than 
last year's (5.48 percent) due in part to the fact that because the 
transition period ends after FY 2001, there is no longer an increase in 
the Federal blend percentage, which increased from 90 to 100 percent 
from FY 2000 to FY 2001, for fully prospective hospitals.

                                           Table III.--Impact of Changes for FY 2002 on Payments Per Discharge
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              Adjusted     Average        Hold                                 Percent
                                                   Number of    Discharges    federal      federal      harmless    Exceptions     Total     change over
                                                   hospitals                  payment      percent      payment      payment      payment      FY 2001
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2001 Payments per Discharge:
  Low Cost Hospitals............................        3,127    6,769,127      $620.00        99.66        $2.99        $5.30      $628.28  ...........
    Fully Prospective...........................        2,942    6,276,252       621.64       100.00  ...........         4.89       626.53  ...........
    100% Federal Rate...........................          169      456,256       617.75       100.00  ...........         6.16       623.91  ...........

[[Page 40096]]

 
    Hold Harmless...............................           16       36,620       366.68        48.18       552.28        64.01       982.96  ...........
  High Cost Hospitals...........................        1,580    4,165,866       632.93        98.07        16.77         9.18       658.87  ...........
    100% Federal Rate...........................        1,408    3,837,475       644.77       100.00  ...........         7.11       651.88  ...........
    Hold Harmless...............................          172      328,391       494.55        75.83       212.71        33.31       740.57  ...........
  Total Hospitals...............................        4,707   10,934,994       624.92        99.04         8.24         6.77       639.94  ...........
FY 2002 Payments per Discharge:
  Low Cost Hospitals............................        3,127    6,877,112       643.74       100.00  ...........         2.85       646.59         2.91
    Fully Prospective...........................        2,942    6,376,366       643.23       100.00  ...........         2.92       646.14         3.13
    100% Federal Rate...........................          185      500,747       650.23       100.00  ...........         2.07       652.29         4.55
  High Cost Hospitals...........................        1,580    4,232,640       667.73       100.00  ...........         5.55       673.28         2.19
    100% Federal Rate...........................        1,580    4,232,640       667.73       100.00  ...........         5.55       673.28         3.28
  Total Hospitals...............................        4,707   11,109,753       652.88       100.00  ...........         3.88       656.76         2.63
--------------------------------------------------------------------------------------------------------------------------------------------------------

    We project that low capital cost hospitals paid under the fully 
prospective payment methodology will experience an average increase in 
payments per case of 2.91 percent, and high capital cost hospitals will 
experience an average increase of 2.19 percent. These results are due 
to the fact that there is no longer an increase in the Federal blend 
percentage with the conclusion of the capital transition period in FY 
2001 for fully prospective hospitals. Beginning FY 2002, all hospitals 
(except ``new'' hospitals under Sec. 412.324(b)) are paid based on 100 
percent of the Federal rate for FY 2002.
    For hospitals paid under the fully prospective payment methodology, 
the Federal rate payment percentage remains at 100 percent from FY 2001 
(the last year of the transition period) and since they no longer 
receive payments based on the hospital-specific rate. The Federal rate 
payment percentage in FY 2001 for hospitals paid under the hold-
harmless payment methodology is based on the hospital's ratio of new 
capital costs to total capital costs. The average Federal rate payment 
percentage for high cost hospitals receiving a hold-harmless payment 
for old capital in FY 2001 will increase from 75.83 percent to 100 
percent since the transition period will have ended. All hold-harmless 
hospitals (except ``new'' hospitals under Sec. 413.324(b)) will be paid 
based on 100 percent of the Federal rate in FY 2002. We estimate that 
high cost hospitals (paid based on 100 percent of the Federal rate) 
will receive a decrease in exceptions payments from $7.11 per discharge 
in FY 2001 to $5.55 per discharge in FY 2002. This is primarily due to 
the expiration of the regular exceptions provision in FY 2002.
    We are no longer presenting the average hospital-specific rate 
payment per discharge in Table III because, beginning with FY 2001, the 
transition blend percentage for fully prospective hospitals is 100 
percent of the Federal rate and zero percent of the hospital-specific 
rate, and all hospitals (except ``new'' hospitals under 
Sec. 412.324(b)) will be paid based on 100 percent of the Federal rate 
for FY 2002.
    As stated previously, we will continue to pay regular exceptions 
for cost reporting periods beginning before October 1, 2001, but ending 
in FY 2002. However, in FY 2003 and later, regular exception payments 
will no longer be made under the regular exceptions provision but 
eligible hospitals could receive special exception payments under 
Sec. 412.348(g).
    We estimate that regular exceptions payments will decrease from 
1.06 percent of total capital payments in FY 2001 to 0.59 percent of 
payments in FY 2002. These results are primarily due to the expiration 
of the regular exceptions after FY 2001 and the limited nature of the 
special exceptions policy in FY 2002. The projected distribution of the 
exception payments is shown in the chart below:

                  Estimated FY 2002 Exceptions Payments
------------------------------------------------------------------------
                                                              Percent of
               Type of hospital                  Number of    exceptions
                                                 hospitals     payments
------------------------------------------------------------------------
Low Capital Cost..............................          104           46
High Capital Cost.............................          112           54
                                               -------------------------
    Total.....................................          216          100
------------------------------------------------------------------------

    In the past we presented a cross-sectional summary of hospital 
groupings by the capital prospective payment transition period 
methodology generated by our actuarial model (Appendix B). We are no 
longer including such a comparison since all hospitals (except ``new'' 
hospitals under Sec. 412.324(b)) will be paid based on 100 percent of 
the Federal rate in FY 2002 with the conclusion of the 10-year capital 
transition period.

C. Cross-Sectional Analysis of Changes in Aggregate Payments

    We used our FY 2002 actuarial model to estimate the potential 
impact of our changes for FY 2002 on total capital payments per case, 
using a universe of 4,707 hospitals. The individual hospital payment 
parameters are taken from the best available data, including: the April 
1, 2001 update to the provider-specific file, cost report data, and 
audit information supplied by intermediaries. In Table IV, we present 
the results of the cross-sectional analysis using the results of our 
actuarial model and the aggregate impact of the FY 2002 payment 
policies. As we explain in Appendix B of this final rule, we were not 
able to use 88 of the 4,795 hospitals in our database due to 
insufficient (missing or unusable) data. Consequently, the payment 
methodology distribution is based on 4,707 hospitals. These data should 
be fully representative of the payment methodologies that will be 
applicable to hospitals. Columns 3 and 4 show estimates of payments per 
case under our model for FY 2001 and FY 2002, respectively. Column 5 
shows the total percentage change in payments from FY 2001 to FY 2002. 
Column 6 presents the percentage change in payments that can be 
attributed to Federal rate changes alone.
    Federal rate changes represented in Column 6 include the 2.28 
percent increase in the Federal rate, a 1.0 percent increase in case 
mix, changes in the adjustments to the Federal rate (for example, the 
effect of the new hospital wage index on the geographic adjustment 
factor), and reclassifications by the MGCRB. Column 5 includes the 
effects of the Federal rate changes represented in Column 6. Column 5 
also reflects the effects of all other changes, including the change 
for all hold-harmless hospitals being paid based on 100 percent of the 
Federal rate, and changes in exception payments. The comparisons are 
provided by: (1)

[[Page 40097]]

geographic location, (2) region, and (3) payment classification.
    The simulation results show that, on average, capital payments per 
case can be expected to increase 2.6 percent in FY 2002. The results 
show that the effect of the Federal rate change alone is to increase 
payments by 3.4 percent. In addition to the increase attributable to 
the Federal rate change, a 0.8 percent decrease is attributable to the 
effects of all other changes.
    Our comparison by geographic location shows an overall increase in 
payments to hospitals in all areas. This comparison also shows that 
urban and rural hospitals will experience slightly different rates of 
increase in capital payments per case (2.7 percent and 2.0 percent, 
respectively). This difference is due to the lower rate of decrease for 
urban hospitals relative to rural hospitals (0.7 percent and 1.4 
percent, respectively) from the effect of all other changes. Urban 
hospitals will gain the same as rural hospitals (3.4 percent) from the 
effects of Federal rate changes alone.
    Most regions are estimated to receive increases in total capital 
payments per case, partly due to the fact that payments to all 
hospitals (except ``new'' hospitals under Sec. 412.324(b)) will be 
based on 100 percent of the Federal rate in FY 2002. Changes by region 
vary from a minimum increase of 0.7 percent (Mountain rural region) to 
a maximum increase of 3.5 percent (East North Central region).
    By type of ownership, voluntary hospitals are projected to have the 
largest rate of increase of total payment changes (2.8 percent, a 3.4 
percent increase due to the Federal rate changes, and a 0.6 percent 
decrease from the effects of all other changes). Similarly, payments to 
government hospitals will increase 2.2 percent (a 3.4 percent increase 
due to Federal rate changes, and a 1.2 percent decrease from the 
effects of all other changes), while payments to proprietary hospitals 
will increase 0.9 percent (a 3.3 percent increase due to Federal rate 
changes, and a 2.4 percent decrease from the effects of all other 
changes). This 2.4 percent decrease from all other changes is primarily 
due to the estimated decrease in exceptions payments and the change for 
all hold-harmless hospitals being paid based on 100 percent of the 
Federal rate.
    Section 1886(d)(10) of the Act established the MGCRB. Hospitals may 
apply for reclassification for purposes of the standardized amount, 
wage index, or both and for purposes of DSH for FYs 1999 through 2001. 
Although the Federal capital rate is not affected, a hospital's 
geographic classification for purposes of the operating standardized 
amount does affect a hospital's capital payments as a result of the 
large urban adjustment factor and the disproportionate share adjustment 
for urban hospitals with 100 or more beds. Reclassification for wage 
index purposes also affects the geographic adjustment factor, since 
that factor is constructed from the hospital wage index.
    To present the effects of the hospitals being reclassified for FY 
2002 compared to the effects of reclassification for FY 2001, we show 
the average payment percentage increase for hospitals reclassified in 
each fiscal year and in total. For FY 2002 reclassifications, we 
indicate those hospitals reclassified for standardized amount purposes 
only, for wage index purposes only, and for both purposes. The 
reclassified groups are compared to all other nonreclassified 
hospitals. These categories are further identified by urban and rural 
designation.
    Hospitals reclassified for FY 2002 as a whole are projected to 
experience a 2.5 percent increase in payments (a 3.4 percent increase 
attributable to Federal rate changes and a 0.9 percent decrease 
attributable to the effects of all other changes). Payments to 
nonreclassified hospitals will increase slightly more (2.6 percent) 
than reclassified hospitals (2.5 percent) overall. Payments to 
nonreclassified hospitals will increase the same as reclassified 
hospitals from the Federal rate changes (3.4 percent), and they will 
lose slightly less from the effects of all other changes (0.8 percent 
compared to 0.9 percent, respectively).

                                Table IV.--Comparison of Total Payments Per Case
                                 [FY 2001 Payments compared to FY 2002 payments]
----------------------------------------------------------------------------------------------------------------
                                                              Average FY   Average FY                  Portion
                                                 Number of       2001         2002                  attributable
                                                 hospitals    payments/    payments/   All charges    to federal
                                                                 case         case                   rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
  All hospitals...............................        4,707          640          657          2.6           3.4
  Large urban areas (populations over 1               1,518          742          763          2.9           3.4
   million)...................................
  Other urban areas (populations of 1 million         1,110          629          645          2.5           3.4
   fewer).....................................
  Rural areas.................................        2,079          433          442          2.0           3.4
  Urban hospitals.............................        2,628          693          712          2.7           3.4
    0-99 beds.................................          638          504          501         -0.6           3.2
    100-199 beds..............................          932          591          604          2.3           3.3
    200-299 beds..............................          527          662          681          2.9           3.4
    300-499 beds..............................          382          734          757          3.2           3.4
    500 or more beds..........................          149          890          917          3.0           3.4
  Rural hospitals.............................        2,079          433          442          2.0           3.4
    0-49 beds.................................        1,218          364          371          1.7           3.3
    50-99 beds................................          516          406          414          1.9           3.3
    100-149 beds..............................          203          443          450          1.8           3.4
    150-199 beds..............................           75          482          494          2.4           3.3
    200 or more beds..........................           67          541          553          2.2           3.4
By Region:
  Urban by Region.............................        2,628          693          712          2.7           3.4
    New England...............................          137          733          757          3.4           3.5
    Middle Atlantic...........................          406          776          797          2.6           3.3
    South Atlantic............................          391          665          682          2.5           3.4
    East North Central........................          445          666          690          3.5           3.4
    East South Central........................          156          628          643          2.4           3.4
    West North Central........................          179          687          708          3.0           3.4

[[Page 40098]]

 
    West South Central........................          319          659          668          1.4           3.3
    Mountain..................................          126          681          690          1.3           3.4
    Pacific...................................          423          783          808          3.3           3.4
    Puerto Rico...............................           46          290          299          3.1           3.1
  Rural by Region.............................        2,079          433          442          2.0           3.4
    New England...............................           50          519          530          2.1           3.4
    Middle Atlantic...........................           74          453          467          3.1           3.4
    South Atlantic............................          269          449          455          1.2           3.3
    East North Central........................          276          441          452          2.4           3.4
    East South Central........................          260          403          412          2.2           3.4
    West North Central........................          479          421          430          2.3           3.4
    West South Central........................          327          388          393          1.4           3.3
    Mountain..................................          195          458          461          0.7           3.2
    Pacific...................................          144          513          528          3.0           3.4
By Payment Classification:
  All hospitals...............................        4,707          640          657          2.6           3.4
  Large urban areas (populations over 1               1,589          735          756          2.8           3.4
   million)...................................
  Other urban areas (populations of 1 million         1,081          631          647          2.5           3.4
   or fewer)..................................
  Rural areas.................................        2,037          431          440          2.1           3.4
  Teaching Status:
    Non-teaching..............................        3,582          526          536          2.0           3.4
    Fewer than 100 Residents..................          888          668          689          3.1           3.4
    100 or more Residents.....................          237          996        1,027          3.1           3.4
  Urban DSH:
    100 or more beds..........................        1,374          729          750          2.8           3.4
    Less than 100 beds........................          309          483          486          0.5           3.2
  Rural DSH:
  Sole Community (SCH/EACH)...................          545          395          395          0.1           3.2
    Referral Center (RRC/EACH)................          152          495          505          1.9           3.4
  Other Rural:
      100 or more beds........................           70          407          418          2.6           3.3
      Less than 100 beds......................          449          366          378          3.0           3.4
  Urban teaching and no DSH:
    Both teaching and DSH.....................          757          805          829          3.0           3.4
    Teaching and no DSH.......................          297          712          737          3.4           3.4
    No teaching and DSH.......................          926          583          596          2.2           3.3
    No teaching and no DSH....................          690          577          587          1.7           3.4
  Rural Hospital Types:
  Non special status hospitals................          794          381          392          3.1           3.4
  RRC/EACH....................................          165          498          513          3.0           3.4
    SCH/EACH..................................          680          417          418          0.2           3.2
    Medicare-dependent hospitals (MDH)........          328          353          363          2.8           3.4
    SCH, RRC and EACH.........................           70          500          503          0.6           3.3
  Hospitals Reclassified by the Medicare
   Geographic Classification Review Board:
  Reclassification Status During FY01 and
   FY02:
      Reclassified During Both FY01 and FY02..          475          560          573          2.4           3.4
    Reclassified During FY02 Only.............          152          558          573          2.7           3.4
    Reclassified During FY01 Only.............           51          489          504          3.0           3.4
  FY02 Reclassifications:
    All Reclassified Hospitals................          627          559          573          2.5           3.4
  All Nonclassified Hospitals.................        4,159          652          670          2.6           3.4
    All Urban Reclassified Hospitals..........          117          742          765          3.1           3.4
    Urban nonreclassified Hospitals...........        2,473          692          711          2.7           3.4
    All Reclassified Rural Hospitals..........          510          486          496          2.1           3.4
    Rural Nonreclassified Hospitals...........        1,566          384          391          1.8           3.3
  Other Reclassified Hospitals (Section                  41          439          452          3.0           3.4
   1886(D)(8)(B)).............................
Type of Ownership:
  Voluntary...................................        2,327          654          672          2.8           3.4
  Proprietary.................................          627          632          637          0.9           3.3
  Government..................................          954          558          570          2.2           3.4
Medicare Utilization as a Percent of Inpatient
 Days:
    0-25......................................          390          831          854          2.7           3.4
    25-50.....................................        1,873          729          750          3.0           3.4
    50-65.....................................        1,832          561          576          2.6           3.4
    Over 65...................................          585          514          516          0.3           3.3
----------------------------------------------------------------------------------------------------------------


[[Page 40099]]

Appendix B:

    Technical Appendix on the Capital Cost Model and Required 
Adjustments
    Under section 1886(g)(1)(A) of the Act, we set capital 
prospective payment rates for FY 1992 through FY 1995 so that 
aggregate prospective payments for capital costs were projected to 
be 10 percent lower than the amount that would have been payable on 
a reasonable cost basis for capital-related costs in that year. To 
implement this requirement, we developed the capital acquisition 
model to determine the budget neutrality adjustment factor. Even 
though the budget neutrality requirement expired effective with FY 
1996, we must continue to determine the recalibration and geographic 
reclassification budget neutrality adjustment factor and the 
reduction in the Federal and hospital-specific rates for exceptions 
payments. To determine these factors, we must continue to project 
capital costs and payments.
    We will continue to pay regular exceptions for cost reporting 
periods beginning before October 1, 2001 but ending in FY 2002. In 
FY 2003 and later, no payments will be made under the regular 
exceptions policy; hence, we will not compute a budget neutrality 
factor for regular exceptions in FY 2003 and later. As described in 
section V.D. of the preamble of this final rule, the budget 
neutrality adjustment for special exceptions will be based on 
historical costs. Consequently, there will be no need to estimate 
capital costs with the capital acquisition model. We will not 
publish this appendix after this final rule for the FY 2002 capital 
rates.
    We used the capital acquisition model from the start of 
prospective payments for capital costs through FY 1997. We now have 
8 years of cost reports under the capital prospective payment 
system. For FY 1998, we developed a new capital cost model to 
replace the capital acquisition model. This revised model makes use 
of the data from these cost reports.
    The following cost reports are used in the capital cost model 
for this proposed rule: the March 31, 2001 update of the cost 
reports for PPS-IX (cost reporting periods beginning in FY 1992), 
PPS-X (cost reporting periods beginning in FY 1993), PPS-XI (cost 
reporting periods beginning in FY 1994), PPS-XII (cost reporting 
periods beginning in FY 1995), PPS-XIII (cost reporting periods 
beginning in FY 1996), PPS-XIV (cost reporting periods beginning in 
FY 1997), PPS-XV (cost reporting periods beginning in FY 1998), and 
PPS-XVI (cost reporting periods beginning in FY 1999). In addition, 
to model payments, we use the April 1, 2001 update of the provider-
specific file, and the March 1995 update of the intermediary audit 
file.
    Since hospitals under alternative payment system waivers (that 
is, hospitals in Maryland) are currently excluded from the capital 
prospective payment system, we excluded these hospitals from our 
model.
    We developed FY 1992 through FY 2001 hospital-specific rates 
using the provider-specific file and the intermediary audit file. 
(We used the cumulative provider-specific file, which includes all 
updates to each hospital's records, and chose the latest record for 
each fiscal year.) We checked the consistency between the provider-
specific file and the intermediary audit file. We ensured that 
increases in the hospital-specific rates were at least as large as 
the published updates (increases) for the hospital-specific rates 
each year. We were able to match hospitals to the files as shown in 
the following table:

------------------------------------------------------------------------
                                                           Number of
                        Source                             hospitals
------------------------------------------------------------------------
No Match.............................................                  1
Provider-Specific File Only..........................                188
Provider-Specific and Audit File.....................              4,606
                                                      ------------------
    Total............................................              4,795
------------------------------------------------------------------------

    One hundred sixteen of the 4,795 hospitals had unusable or 
missing data, or had no cost reports available. For 50 of the 116 
hospitals, we were unable to determine a hospital-specific rate from 
the available cost reports. However, there was adequate cost 
information to determine that these hospitals were paid under the 
hold-harmless methodology. Since the hospital-specific rate is not 
used to determine payments for hospitals paid under the hold-
harmless methodology, there was sufficient cost report information 
available to include these 50 hospitals in the analysis. We were 
able to estimate hospital-specific amounts from the cost reports as 
shown in the following table.

------------------------------------------------------------------------
                                                              Number of
                        Cost report                           hospitals
------------------------------------------------------------------------
PPS-9......................................................            1
PPS-12.....................................................            1
PPS-13.....................................................            1
PPS-14.....................................................            1
PPS-15.....................................................            2
PPS-16.....................................................           13
                                                            ------------
    Total..................................................           19
------------------------------------------------------------------------

    Hence, we were able to use 69 (50 plus 19) of the 116 hospitals. 
The remaining 47 of the 116 hospitals could not be used in the 
analysis because we were not able to estimate their hospital-
specific amount. An additional 41 hospitals could not be used in the 
analysis because we could not determine their capital costs, either 
because we had no cost reports for them or because there was 
insufficient cost report data. Accordingly, we used 4,707 hospitals 
for the analysis. Eighty-eight (47 plus 41) hospitals could not be 
used in the analysis because of insufficient (missing or unusable) 
information. These hospitals account for about 0.3 percent of 
admissions. Therefore, any effects from the elimination of their 
cost report data should be minimal.
    We analyzed changes in capital-related costs (depreciation, 
interest, rent, leases, insurance, and taxes) reported in the cost 
reports. We found a wide variance among hospitals in the growth of 
these costs. For hospitals with more than 100 beds, the distribution 
and mean of these cost increases were different for large changes in 
bed-size (greater than 20 percent). We also analyzed 
changes in the growth in old capital and new capital for cost 
reports that provided this information. For old capital, we limited 
the analysis to decreases in old capital. We did this since the 
opportunity for most hospitals to treat ``obligated'' capital put 
into service as old capital has expired. Old capital costs should 
decrease as assets become fully depreciated and as interest costs 
decrease as the loan is amortized.
    The new capital cost model separates the hospitals into three 
mutually exclusive groups. Hold-harmless hospitals with data on old 
capital were placed in the first group. Of the remaining hospitals, 
those hospitals with fewer than 100 beds comprise the second group. 
The third group consists of all hospitals that did not fit into 
either of the first two groups. Each of these groups displayed 
unique patterns of growth in capital costs. We found that the gamma 
distribution is useful in explaining and describing the patterns of 
increase in capital costs. A gamma distribution is a statistical 
distribution that can be used to describe patterns of growth rates, 
with the greatest proportion of rates being at the low end. We use 
the gamma distribution to estimate individual hospital rates of 
increase as follows:
    (1) For hold-harmless hospitals, old capital cost changes were 
fitted to a truncated gamma distribution, that is, a gamma 
distribution covering only the distribution of cost decreases. New 
capital costs changes were fitted to the entire gamma distribution, 
allowing for both decreases and increases.
    (2) For hospitals with fewer than 100 beds (small), total 
capital cost changes were fitted to the gamma distribution, allowing 
for both decreases and increases.
    (3) Other (large) hospitals were further separated into three 
groups:
     Bed-size decreases over 20 percent (decrease).
     Bed-size increases over 20 percent (increase).
     Other (no change).
    Capital cost changes for large hospitals were fitted to gamma 
distributions for each bed-size change group, allowing for both 
decreases and increases in capital costs. We analyzed the 
probability distribution of increases and decreases in bed size for 
large hospitals. We found the probability somewhat dependent on the 
prior year change in bed size and factored this dependence into the 
analysis. Probabilities of bed-size change were determined. Separate 
sets of probability factors were calculated to reflect the 
dependence on prior year change in bed size (increase, decrease, and 
no change).
    The gamma distributions were fitted to changes in aggregate 
capital costs for the entire hospital. We checked the relationship 
between aggregate costs and Medicare per discharge costs. For large 
hospitals, there was a small variance, but the variance was larger 
for small hospitals. Since costs are used only for the hold-harmless 
methodology and to determine exceptions, we decided to use the gamma 
distributions fitted to aggregate cost increases for estimating 
distributions of cost per discharge increases.
    Capital costs per discharge calculated from the cost reports 
were increased by random

[[Page 40100]]

numbers drawn from the gamma distribution to project costs in future 
years. Old and new capital were projected separately for hold-
harmless hospitals. Aggregate capital per discharge costs were 
projected for all other hospitals. Because the distribution of 
increases in capital costs varies with changes in bed size for large 
hospitals, we first projected changes in bed size for large 
hospitals before drawing random numbers from the gamma distribution. 
Bed-size changes were drawn from the uniform distribution with the 
probabilities dependent on the previous year bed-size change. The 
gamma distribution has a shape parameter and a scaling parameter. 
(We used different parameters for each hospital group, and for old 
and new capital.)
    We used discharge counts from the cost reports to calculate 
capital cost per discharge. To estimate total capital costs for FY 
2000 (the MedPAR data year) and later, we use the number of 
discharges from the MedPAR data. Some hospitals had considerably 
more discharges in FY 2000 than in the years for which we calculated 
cost per discharge from the cost report data. Consequently, a 
hospital with few cost report discharges would have a high capital 
cost per discharge, since fixed costs would be allocated over only a 
few discharges. If discharges increase substantially, the cost per 
discharge would decrease because fixed costs would be allocated over 
more discharges. If the projection of capital cost per discharge is 
not adjusted for increases in discharges, the projection of 
exceptions would be overstated. We address this situation by 
recalculating the cost per discharge with the MedPAR discharges if 
the MedPAR discharges exceed the cost report discharges by more than 
20 percent. We do not adjust for increases of less than 20 percent 
because we have not received all of the FY 2000 discharges, and we 
have removed some discharges from the analysis because they are 
statistical outliers. This adjustment reduces our estimate of 
exceptions payments, and consequently, the reduction to the Federal 
rate for exceptions is smaller. We will continue to monitor our 
modeling of exceptions payments and make adjustments as needed.
    The average national capital cost per discharge generated by 
this model is the combined average of many randomly generated 
increases. This average must equal the projected average national 
capital cost per discharge, which we projected separately (outside 
this model). We adjusted the shape parameter of the gamma 
distributions so that the modeled average capital cost per discharge 
matches our projected capital cost per discharge. The shape 
parameter for old capital was not adjusted since we are modeling the 
aging of ``existing'' assets. This model provides a distribution of 
capital costs among hospitals that is consistent with our aggregate 
capital projections.
    Once each hospital's capital-related costs are generated, the 
model projects capital payments. We use the actual payment 
parameters (for example, the case-mix index and the geographic 
adjustment factor) that are applicable to the specific hospital.
    To project capital payments, the model first assigns the 
applicable payment methodology (fully prospective or hold-harmless) 
to the hospital as determined from the provider-specific file and 
the cost reports. The model simulates Federal rate payments using 
the assigned payment parameters and hospital-specific estimated 
outlier payments. The case-mix index for a hospital is derived from 
the FY 2000 MedPAR file using the FY 2002 DRG relative weights 
included in section VI. of the Addendum to this final rule. The 
case-mix index is increased each year after FY 2000 based on 
analysis of past experiences in case-mix increases. Based on 
analysis of recent case-mix increases, we estimate that case-mix 
will decrease 0.9 percent in FY 2001. We project that case-mix will 
increase 1.0 percent in FY 2002. (Since we are using FY 2000 cases 
for our analysis, the FY 2000 increase in case-mix has no effect on 
projected capital payments.)
    Changes in geographic classification and revisions to the 
hospital wage data used to establish the hospital wage index affect 
the geographic adjustment factor. Changes in the DRG classification 
system and the relative weights affect the case-mix index.
    Section 412.308(c)(4)(ii) requires that the estimated aggregate 
payments for the fiscal year, based on the Federal rate after any 
changes resulting from DRG reclassifications and recalibration and 
the geographic adjustment factor, equal the estimated aggregate 
payments based on the Federal rate that would have been made without 
such changes. For FY 2001, the budget neutrality adjustment factors 
were 0.99933 for the national rate and 1.00508 for the Puerto Rico 
rate. In determining these factors, we used the factors from the 
first half of FY 2001 (October 2000 through March 2001) published in 
the August 1, 2000 final rule since section 547 of Public Law 106-
554 specifies that the special increases and adjustments in effect 
between April and October 2001 do not apply for discharges occurring 
after FY 2001 and should not be included in determining the payment 
rates in subsequent years.
    Since we implemented a separate geographic adjustment factor for 
Puerto Rico, we applied separate budget neutrality adjustments for 
the national geographic adjustment factor and the Puerto Rico 
geographic adjustment factor. We applied the same budget neutrality 
factor for DRG reclassifications and recalibration nationally and 
for Puerto Rico. Separate adjustments were unnecessary for FY 1998 
and earlier since the geographic adjustment factor for Puerto Rico 
was implemented in FY 1998.
    To determine the factors for FY 2002, we first determined the 
portions of the Federal national and Puerto Rico rates that would be 
paid for each hospital in FY 2002 based on its applicable payment 
methodology. Using our model, we then compared, separately for the 
national rate and the Puerto Rico rate, estimated aggregate Federal 
rate payments based on the FY 2001 DRG relative weights and the FY 
2001 geographic adjustment factor to estimated aggregate Federal 
rate payments based on the FY 2001 relative weights and the FY 2002 
geographic adjustment factor. In making the comparison, we held the 
FY 2002 Federal rate portion constant and set the other budget 
neutrality adjustment factor and the regular and special exceptions 
reduction factors to 1.00. To achieve budget neutrality for the 
changes in the national geographic adjustment factor, we applied an 
incremental budget neutrality adjustment of 0.99666 for FY 2002 to 
the previous cumulative FY 2001 adjustment of 0.99933, yielding a 
cumulative adjustment of 0.99599 through FY 2002. For the Puerto 
Rico geographic adjustment factor, we applied an incremental budget 
neutrality adjustment of 0.98991 for FY 2002 to the previous 
cumulative FY 2001 adjustment of 1.00508, yielding a cumulative 
adjustment of 0.99494 through FY 2002. We then compared estimated 
aggregate Federal rate payments based on the FY 2001 DRG relative 
weights and the FY 2002 geographic adjustment factors to estimated 
aggregate Federal rate payments based on the FY 2002 DRG relative 
weights and the FY 2002 geographic adjustment factors. The 
incremental adjustment for DRG classifications and changes in 
relative weights is 0.99668 nationally and for Puerto Rico. The 
cumulative adjustments for DRG classifications and changes in 
relative weights and for changes in the geographic adjustment 
factors through FY 2002 are 0.99268 nationally and 0.99164 for 
Puerto Rico. The following table summarizes the adjustment factors 
for each fiscal year:

                     Budget Neutrality Adjustment For DRG Reclassifications and Recalibration and the Geographic Adjustment Factors
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                   National                                             Puerto Rico
                                           -------------------------------------------------------------------------------------------------------------
                                                      Incremental adjustment                                 Incremental adjustment
                                           -------------------------------------------            -------------------------------------------
                Fiscal year                 Geographic                                             Geographic
                                                               DRG                     Cumulative                     DRG                     Cumulative
                                            adjustment  reclassifications   Combined               adjustment  reclassifications   Combined
                                              factor    and recalibration                            factor    and recalibration
--------------------------------------------------------------------------------------------------------------------------------------------------------
1992......................................  ..........  .................  ..........     1.00000  ..........  .................  ..........  ..........
1993......................................  ..........  .................     0.99800     0.99800  ..........  .................  ..........  ..........

[[Page 40101]]

 
1994......................................  ..........  .................     1.00531     1.00330  ..........  .................  ..........  ..........
1995......................................  ..........  .................     0.99980     1.00310  ..........  .................  ..........  ..........
1996......................................  ..........  .................     0.99940     1.00250  ..........  .................  ..........  ..........
1997......................................  ..........  .................     0.99873     1.00123  ..........  .................  ..........  ..........
1998......................................  ..........  .................     0.99892     1.00015  ..........  .................  ..........     1.00000
1999......................................     0.99944         1.00335        1.00279     1.00294     0.99898         1.00335        1.00233     1.00233
2000......................................     0.99857         0.99991        0.99848     1.00142     0.99910         0.99991        0.99901     1.00134
2001\1\...................................     0.99846         1.00019        0.99865     0.99933     1.00365         1.00009        1.00374     1.00508
2001\2\...................................  \3\ 0.9977     \3\ 1.00009     \3\ 0.9978     0.99922  \3\ 1.0036     \3\ 1.00009     \3\ 1.0037     1.00508
                                                     1                              0                       5                              4
2002......................................  \4\ 0.9966     \4\ 0.99668     \4\ 0.9933     0.99268  \4\ 0.9899     \4\ 0.99668     \4\ 0.9966     0.99164
                                                     6                              5                       1                              2
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Factors effective for the first half of FY 2001 (October 2000 through March 2001).
\2\ Factors effective for the second half of FY 2001 (April 2001 through September 2001).
\3\ Incremental factors are applied to FY 2000 cumulative factors.
\4\ Incremental factors are applied to the cumulative factors for the first half of FY 2001.

    The methodology used to determine the recalibration and 
geographic (DRG/GAF) budget neutrality adjustment factor is similar 
to that used in establishing budget neutrality adjustments under the 
prospective payment system for operating costs. One difference is 
that, under the operating prospective payment system, the budget 
neutrality adjustments for the effect of geographic 
reclassifications are determined separately from the effects of 
other changes in the hospital wage index and the DRG relative 
weights. Under the capital prospective payment system, there is a 
single DRG/GAF budget neutrality adjustment factor (the national 
rate and the Puerto Rico rate are determined separately) for changes 
in the geographic adjustment factor (including geographic 
reclassification) and the DRG relative weights. In addition, there 
is no adjustment for the effects that geographic reclassification 
has on the other payment parameters, such as the payments for 
serving low-income patients or the large urban add-on payments.
    In addition to computing the DRG/GAF budget neutrality 
adjustment factor, we used the model to simulate total payments 
under the prospective payment system.
    Additional payments under the exceptions process are accounted 
for through a reduction in the Federal and hospital-specific rates. 
For FY 2002 additional payments for the ``regular'' exceptions are 
made only for cost reporting periods that begin before October 1, 
2001. The adjustment for ``special'' exceptions payments (see 
Sec. 412.348(g)) is described in section V.D. of the preamble of 
this final rule. Therefore, we used the model to calculate the 
exceptions reduction factor. This exceptions reduction factor 
ensures that aggregate payments under the capital prospective 
payment system, including exceptions payments, are projected to 
equal the aggregate payments that would have been made under the 
capital prospective payment system without an exceptions process. In 
modeling exceptions for FY 2002, we calculated exceptions only for 
qualifying cost reporting periods. Since changes in the level of the 
payment rates change the level of payments under the exceptions 
process, the exceptions reduction factor must be determined through 
iteration.
    In the August 30, 1991 final rule (56 FR 43517), we indicated 
that we would publish each year the estimated payment factors 
generated by the model to determine payments for the next 5 years. 
Since we will no longer use the model after this final rule for the 
FY 2002 rates, we will discontinue publishing this table after this 
final rule for the FY 2002 rates. The table below provides the 
actual factors for FYs 1992 through 2002, and the estimated factors 
that would be applicable through FY 2006. We caution that these are 
estimates for FYs 2003 and later, and are subject to revisions 
resulting from continued methodological refinements, receipt of 
additional data, and changes in payment policy. We note that in 
making these projections, we have assumed that the cumulative 
national DRG/GAF budget neutrality adjustment factor will remain at 
0.99268 (0.99164 for Puerto Rico) for FY 2002 and later because we 
do not have sufficient information to estimate the change that will 
occur in the factor for years after FY 2002.
    The projections are as follows:

----------------------------------------------------------------------------------------------------------------
                                                                                                        Federal
                                          Exceptions    Budget      DRG/GAF     Outlier     Federal      rate
         Fiscal year            Update     reduction  neutrality  adjustment  adjustment     rate       (after
                                factor      factor      factor     factor\1\    factor    adjustment   outlier)
                                                                                                       reduction
----------------------------------------------------------------------------------------------------------------
1992........................         N/A      0.9813      0.9602  ..........       .9497  ..........      415.59
1993........................        6.07       .9756       .9162       .9980       .9496  ..........      417.29
1994........................        3.04       .9485       .8947      1.0053       .9454    \2\.9260      378.34
1995........................        3.44       .9734       .8432       .9998       .9414  ..........      376.83
1996........................        1.20       .9849         N/A       .9994       .9536    \3\.9972      461.96
1997........................        0.70       .9358         N/A       .9987       .9481  ..........      438.92
1998........................        0.90        9659         N/A       .9989       .9382    \4\.8222      371.51
1999........................        0.10       .9783         N/A      1.0028       .9392  ..........      378.10
2000........................        0.30       .9730         N/A       .9985       .9402  ..........      377.03
2001\5\.....................        0.90       .9785         N/A       .9979       .9409  ..........      382.03
2002........................        1.30    \6\.9929         N/A      0.9933       .9424  ..........      390.74
2003........................        0.70       .9975         N/A   \7\1.0000    \7\.9424   \4\1.0255      405.39
2004........................        0.70       .9975         N/A      1.0000       .9424  ..........      408.23
2005........................        0.90       .9975         N/A      1.0000       .9424  ..........      411.90
2006........................        0.90       .9975         N/A      1.0000       .9424  ..........      415.61
----------------------------------------------------------------------------------------------------------------
\1\ The incremental change over the previous year.
\2\ OBRA 1993 adjustment.
\3\ Adjustment for change in the transfer policy.
\4\ Balanced Budget Act of 1997 adjustment.
\5\ Rates are for the first half of FY 2001 (October 1, 2000 through March 31, 2001).
\6\ Product of general exceptions factor (0.9941) and special exceptions factor (0.9988)

[[Page 40102]]

 
\7\ Future adjustments are, for purposes of this projection, assumed to remain at the same level.

Appendix C: Recommendation of Update Factors for Operating Cost Rates 
of Payment for Inpatient Hospital Services

I. Background

    Several provisions of the Act address the setting of update 
factors for inpatient services furnished in FY 2002 by hospitals 
subject to the prospective payment system and by hospitals or units 
excluded from the prospective payment system. Section 
1886(b)(3)(B)(i)(XVII) of the Act, as amended by section 301 of 
Public Law 106-554, sets the FY 2002 percentage increase in the 
operating cost standardized amounts equal to the rate of increase in 
the hospital market basket minus 0.55 percentage points for 
prospective payment hospitals in all areas. Section 
1886(b)(3)(B)(iv) of the Act sets the FY 2002 percentage increase in 
the hospital-specific rates applicable to SCHs and MDHs equal to the 
rate set forth in section 1886(b)(3)(B)(i) of the Act, that is, the 
same update factor as all other hospitals subject to the prospective 
payment system, or the rate of increase in the market basket minus 
0.55 percentage points. Under section 1886(b)(3)(B)(ii) of the Act, 
the FY 2002 percentage increase in the rate-of-increase limits for 
hospitals and units excluded from the prospective payment system 
ranges from the percentage increase in the excluded hospital market 
basket less a percentage between 0 and 2.5 percentage points, 
depending on the hospital's or unit's costs in relation to its limit 
for the most recent cost reporting period for which information is 
available, or 0 percentage point if costs do not exceed two-thirds 
of the limit.
    In accordance with section 1886(d)(3)(A) of the Act, we are 
updating the standardized amounts, the hospital-specific rates, and 
the rate-of-increase limits for hospitals and units excluded from 
the prospective payment system as provided in section 1886(b)(3)(B) 
of the Act. Based on the second quarter 2001 forecast of the FY 2002 
market basket increase of 3.3 percent for hospitals subject to the 
prospective payment system, the update to the standardized amounts 
is 2.75 percent (that is, the market basket rate of increase minus 
0.55 percentage points) for hospitals in both large urban and other 
areas. The update to the hospital-specific rate applicable to SCHs 
and MDHs is also 2.75 percent. The update for hospitals and units 
excluded from the prospective payment system can range from the 
percentage increase in the excluded hospital market basket 
(currently estimated at 3.3 percent) minus a percentage between 0 
and 2.5 percentage points, or 0 percentage point, resulting in an 
increase in the rate-of-increase limit between 0.8 and 3.3 percent, 
or 0 percent.
    Section 1886(e)(4) of the Act requires that the Secretary, 
taking into consideration the recommendations of the Medicare 
Payment Advisory Commission (MedPAC), recommend update factors for 
each fiscal year that take into account the amounts necessary for 
the efficient and effective delivery of medically appropriate and 
necessary care of high quality. In its March 1, 2001 report, MedPAC 
stated that the legislated update of market basket minus 0.55 
percentage points would provide a reasonable level of payments to 
hospitals. MedPAC did not make a separate recommendation for the 
hospital-specific rate applicable to SCHs and MDHs.
    Under section 1886(e)(5) of the Act, we are required to publish 
the update factors recommended under section 1886(e)(4) of the Act. 
Accordingly, we published the FY 2002 update factors recommended by 
the Secretary as Appendix D of the May 4, 2001 proposed rule (66 FR 
22888). In that appendix, we discussed the recommendations of 
appropriate update factors, the analysis underlying our 
recommendations, and our response to MedPAC's recommendations 
concerning the update factors.

I. Secretary's Final Recommendations for Updating the Prospective 
Payment System Standardized Amounts

    In recommending an update, the Secretary takes into account the 
factors in the update framework, as well as the recommendations of 
MedPAC, the long-term solvency of the Medicare Trust Funds, and the 
capacity of the hospital industry to continually provide access to 
high quality care to Medicare beneficiaries through adequate 
reimbursement to health care providers.
    We received several comments concerning our proposed 
recommendation.
    Comment: One commenter questioned the reason for the difference 
between the 3.05 percent update to the standardized amounts 
recommended by the Secretary to the Congress as printed in the May 
4, 2001 proposed rule (65 FR 22885) and the 2.55 percent proposed 
update used to establish the rates printed in the May 4, 2001 
proposed rule (65 FR 22738).
    Response: The President's FY 2002 budget estimated that the 
market basket for FY 2002 would be 3.6 percent. This estimate is 
prepared by the Office of Management and Budget (OMB) by applying 
future assumptions of economy-wide wage and consumer price index 
growth to the historical relationship between these factors and the 
market basket.
    The market basket we have historically used to actually update 
the standardized amounts is estimated by our Office of the Actuary, 
in conjunction with Global Insights, Inc., DRI-WEFA. Although this 
estimate is generally very close to the OMB estimate, there are 
often some discrepancies due to the timing of the estimate and the 
differing future assumptions of the input factors.
    Our final recommendation of the market basket percentage 
increase minus 0.55 percentage points for the update for hospitals 
subject to the prospective payment system, which is consistent with 
current law, did not differ from the proposed. However, the second 
quarter forecast of the market basket percentage increase is 3.3 for 
prospective payment hospitals (up from 3.1 estimated in the proposed 
rule). Thus, the Secretary's final recommendation is that the update 
to the prospective payment system standardized amounts for both 
large urban and other urban areas is 2.75 percent (or consistent 
with current law, market basket percentage increase minus 0.55 
percent). The update to the hospital-specific rate applicable to 
SCHs and MDHs is also 2.75 percent (or consistent with current law, 
market basket percentage increase minus 0.55 percentage points).
    Comment: Several commenters addressed the recent increases in 
the price of blood products. One commenter stated the increases 
represent up to one percent of annual DRG payments for hospitals 
that perform a significant number of surgeries. The commenters urged 
us to ensure that the DRG payments reflect price increases 
associated with rising blood prices.
    Response: Section 301(c) of Public Law 106-554 requires the 
Secretary to consider the price of blood and blood products in the 
market basket index when the market basket is next rebased and 
revised and to determine whether those prices are adequately 
reflected.

III. Secretary's Final Recommendation for Updating the Rate-of-Increase 
Limits for Excluded Hospitals and Units

    We received no comments concerning our proposed recommendation. 
Our final recommendation for excluded hospitals and units did not 
differ from the proposed. However, the second quarter forecast of 
the market basket percentage increase is 3.3 for excluded hospitals 
and units (up from 3.0 estimated in the proposed rule). Thus, the 
Secretary's final recommendation is that the update for hospitals 
and units excluded from the prospective payment system can range 
from market basket increase of 3.3 percent minus a percentage 
between 0 and 2.5 percent, or 0 percent depending on the 
relationship between the hospital's or unit's costs and its rate-of-
increase limit, which results in an increase in the rate-of-increase 
limit between 0.8 and 3.3 percent, or 0 percent for FY 2002.

[FR Doc. 01-18868 Filed 7-31-01; 8:45 am]
BILLING CODE 4120-01-P